DIET  IN  HEALTH 
AND  DISEASE  ' 


BY  K 

JULIUS  FRIEDENWALD,  M.  D. 

PROFESSOR    OF    GASTRO-ENTEROLOGY    IN    THE    UNIVERSITY    OF   MARYLAND    SCHOOL   OF 
MEDICINE   AND  COLLEGE  OF  PHYSICIANS  AND   SURGEONS,  BALTIMORE 


AND 


JOHN  RUHRAH,   M.  D. 


PROFESSOR    OF    DISEASES   OF    CHILDREN   IN    THE    UNH'ERSITY    OF    MARYLAND   SCHOOL 
OF  MEDICINE  AND  COLLEGE  OF  PHYSICIANS  AND   SUTIGEONS,  BALTIMORE 


"  These  few  rules  of  diet  he  that  keeps,  shall  surely 
find  great  ease  and  speedy  remedy  by  it." — Burton 


FIFTH  EDITION,  RESET 


PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS    COMPANY 

1919 


t;s«^ 


Copyright,  1904,  by  W.  B.  Saunders  and  Company.     Reprinted  June,  1905.     Revised,  re- 
printed, and  recopyrighted  May,  1906.     Revised,  reprinted,  and  recopyrighted  April, 
1909.     Reprinted  April,  1910,  and  April,  1911.      Revised,  reprinted,  and  re- 
copyrighted May,  1913.     Reprinted  June,  1915.     Revised,  entirely 
reset,  reprinted,  and  recopyrighted  April,  1919 


Copyright,  1919,  by  W.  B.  Saunders  Company 


P^llNTED    IN    AMERICA 


PRESS    OF 

W.    8.    SAUNDERS    COMPANY 

PHILADELPHIA 


TO 

Sir  milUam  ©sler.  /ID.  2). 

AS  A  SLIGHT  TOKEN  OF  OUR  APPRECIATION  OF  HIS  PERSONAL 

FRIENDSHIP,    OF    MANY    FAVORS,    AND   OF   THE   EN* 

COURAGEMENT  HE  HAS  ALWAYS  GIVEN  THE 

MEMBERS  OF  THE  PROFESSION. 


PREFACE  TO  THE  FIFTH  EDITION 


The  continued  appreciation  of  the  profession  as  evidenced  by  their 
using  this  book  has  added  greatly  to  the  endeavor  to  make  the  fifth 
edition  of  more  value  than  the  preceding  ones. 

There  are  scarcely  an.y  subjects  in  medicine  that  have  received 
the  same  amount  of  attention  of  recent  years  as  dietetics  and  the  study 
of  nutrition.  The  literature  is  voluminous  and  it  would  neither  be 
possible  nor  profitable  to  try  to  include  everything  that  has  been 
brought  forward.  There  are  many  differences  of  opinion  among 
authorities  on  many  questions  which  can  only  be  settled  by  future 
study  and  in  many  cases  the  views  expressed  are  diametrically  op- 
posed. Much  of  our  knowledge  on  nutrition  is  fragmentary  and  the 
exact  value  of  many  contributions  cannot  be  estimated  until  further 
investigations  have  been  made.  Dietetics  has  always  been  a  sub- 
ject much  influenced  by  fads  and  fancies  and  much  of  the  literature 
has  little  value  in  consequence. 

The  authors  have  endeavored  to  give  fully  the  various  facts  relat- 
ing to  the  composition  of  foods,  to  indicate  as  far  as  possible  in  the 
space  of  one  volume  the  scientific  basis,  when  there  is  any,  for  the 
various  diets  and  to  give  at  the  same  time  practical  directions  and 
diet  lists  which  can  be  used  without  extensive  training. 

The  authors  have  attempted  to  bring  together  within  a  compara- 
tively small  number  of  pages  the  best  of  the  modern  thought  upon 
the  subject  and  take  this  opportunity  of  expressing  their  indebted- 
ness to  all  the  authors  quoted.  In  each  instance  an  endeavor  has 
been  made  to  indicate  the  source  of  the  information.  A  number  of 
new  articles  have  been  added,  among  which  may  be  mentioned  those 
on  vitamins,  amino-acids,  acid  and  alkali  content  of  food,  relation 
of  food  to  skin  surface,  milk  standards,  food  allergy,  Sippy's  diet 
in  peptic  .ulcer  and  numerous  smaller  ones.  A  considerable  portion 
of  the  volume  has  been  rewritten  in  part  or  entirely,  including  the 
sections  on  infant  feeding,  rectal  feeding,  diabetes,  obesity,  acidosis, 
the  Karell  cure,  renal  diseases,  and  pellagra  and  the  deficiency  dis- 
eases. 

Through  a  special  arrangement  with  D.  Applet  on  and  Company 
and  Dr.  Edwin  A.  Locke,  it  has  been  possible  to  add  the  valuable 
tables  that  have  been  prepared  by  Dr.  Locke.  The  authors  wish  to 
express  their  indebtedness  to  both.  They  are  indebted  to  the  Direc- 
tor  of  the   Connecticut    Agricultural    Experiment    Station    at   New 

7 


8  .    ,       ,  ^,„    J^f^^FACE  JO  THE  FIFTH  EDITION 

Haven  for  permission  to  use  the  valuable  analyses  oi  diabetic  foods 
which  are  included  under  the  heading  of  diabetes. 

Owing  to  the  war  there  has  been  an  unavoidable  delay  in  the  re- 
setting and  printing  of  the  book  so  that  practically  no  references  will 
be  found  to  literature  later  than  the  first  of  1918. 

The  authors  wish  also  to  express  their  thanks  to  AV.  B.  Saunders 
Company  for  their  uniform  courtesy  and  consideration. 

Baltimore,  April,  1919 


PREFACE  TO  THE  FIRST  EDITION 


This  book  lias  been  prepared  to  meet  the  needs  of  the  general 
practitioner,  hospital  interne,  and  medical  student,  as  well  as  for 
a  reference  handbook  for  training-schools. 

The  aim  of  the  book  is  entirely  practical,  AVe  have  endeavored 
to  give  a  reasonably  concise  account  of  the  diti'erent  kinds  of  foods, 
their  composition  and  uses,  and  also  to  set  forth  the  principles  of 
diet  both  in  health  and  disease.  The  greater  part  of  the  book  is  de- 
voted to  the  sick,  and  we  have  tried  to  tell  the  doctor  how  to  feed 
his  patient.  We  have  gone  over  the  literature  of  the  subject,  much 
of  which  is  inaccessible  to  the  general  practitioner,  and  have  given 
what  seems  to  us  to  be  the  most  useful.  We  trust  that  the  book  is 
simple  enough  to  be  used  for  rapid  reference  by  the  busy  practitioner, 
and  that  there  is  sufficient  detail  to  make  the  way  clear  for  the  med- 
ical student  and  the  uninitiated  hospital  interne.  We  have  gathered 
together  many  diet-lists  and  recipes,  which  we  trust  will  be  of  service 
both  to  the  physician  and  to  the  nurse. 

In  the  preparation  of  this  work  we  have  consulted  many  books  and 
journal  articles,  and  we  are  under  obligation  to  the  many  authors 
whose  names  are  mentioned  throughout  the  book  in  connection  with 
their  contributions  to  the  science  of  dietetics. 

We  are  especially  indebted  to  Dr.  W.  O.  Atwater  and  his  collabora- 
tors for  much  valuable  material.  We  wish  to  express  our  thanks  to 
the  publishers,  Messrs.  W.  B.  Saunders  &  Co.,  for  the  courtesy  they 
have  shown  in  its  preparation. 


CONTENTS 


PAGE 

The  Chemistry  and  Physiology  of  Digestion 17 

Digestion  and  Absorption 24 

Digestion         24 

Peculiarities  of  the  Digestion  in  Infants 34 

Absorption 36 

The  Influence  of  Various  Factors  upon  the  Digestion 40 

Metabolism 42 

Foods  and  Their  Composition 46 

Dietaries  and  Dietary  Standards 69 

Classes  of  Foods 93 

Animal  Foods 93 

Milk  and  Milk  Products 93 

Eggs 117 

Meats  and  the  Meat  Preparations 120 

Fish 126 

Vegetable  Foods 129 

Cereals 130 

Legumes 134 

Roots  and  Tubers 138 

Green  Vegetables 139 

Fruits  and  Nuts 142 

Fruits 142 

Nuts 144 

Fungi,  Algae,  and  Lichens 146 

Sugars 147 

Spices  and  Condiments 149 

Fats  and  Oils 150 

Salts 154 

Salt  Metabolism  and  Disease 164 

Phosphorus-containing  Foods 165 

Potassium-containing  Foods 165 

Sodium-containing  Foods 165 

Iron-containing  Foods 165 

Sulphur-containing  Foods 166 

Chlorine-containing  Foods 166 

Magnesium-containing  Foods 166 

Calcium-containing  Foods 166 

Beverages  and  Stimulants 167 

Water 167 

Mineral  Waters 168 

Tea 177 

Coff-ee 179 

Cocoa 180 

Alcohol 181 

Spirits 1S6 

Liqueurs  and  Bitters 187 

Malt  Liquors 187 

Wines         190 

Action  and  Therapeutic  Use  of  Malt  Liquors  and  Wines 196 

Cider 196 

11 


12       ,'.:  '^ ''.',".''';': '    '  /.   contents 

PAGE 

Vabious  Factors  in  Theib  Bearing  on  Diet 198 

Concentration  of  Food 198 

Preservation  of  Food 198 

Artificial  Food  Preparations 200 

Artificial  Proprietary  Foods ...  203 

Cooking  of  Foods 206 

Efi'ect  of  Cooking 207 

Diseases  Caused  by  Errors  in  Diet  and  by  Various  Food-poisons  .            .  209 

Other  Forms  of  Food-poisoning                                                          ...  219 

Idiosyncrasies 221 

Food  Adulteration 228 

Simple  Tests  for  Detection  of  Preservatives 235 

The  Determination  of  Artificial  Colors 236 

The  Examination  of  Various  Foods 238 

Diet  as  a  Means  of  Diagnosis 239 

Diet  for  Singers  and  Speakers 242 

Diet  During  Athletic  Training 243 

Infant  Feeding 251 

Milk  Modification 279 

Methods  of  Practical  Value  in  Modifying  Milk 279 

Other  Foods  for  Infants 297 

Feeding  During  the  Second  Year 306 

Diet  of  School  Children 314 

Other  Factors  in  Infant  Feeding 319 

Gavage 324 

Diet  in  Diseases  of  Children 325 

Diet  fob  Special  Conditions 344 

Diet  for  the  Aged 344 

Diet  During  Pregnancy  and  the  Puerperium 347 

Diet  in  the  Special  Diseases  of  Pregnancy ...  349 

The  Effect  of  Diet  on  the  Development  and  Structure  of  the  Uterus     .  350 

Special  Methods  OF  Feeding .351 

Rectal  Feeding 351 

Indications  for  the  Use  of  Nutrient  Enemata 355 

Other  Methods  of  Nourishing  the  Body 356 

Diet  in  Disease 362 

Feeding  in  Fever 365 

Feeding  in  Infectious  Diseases .371 

Typhoid  Fever 371 

Atypical 385 

Complicated 385 

Typhus  Fever 386 

Small-pox 386 

Scarlet  Fever 387 

Measles 389 

Mumps 389 

Whooping-cough        389 

Influenza         390 

Meningitis  and  Cerebrospinal  Fever 390 

Diphtheria .  391 

Erysipelas 392 

Rheumatism         ...            393 

Asiatic    Cholera 394 

Yellow    Fever 396 

Dengue 397 

Malaria 397 

Sprue         398 

Tetanus 398 

Rabies 399 


CONTENTS  13 

Diet  in  Disease  (Continued) .  page 

Tuberculosis          399 

Diet  in  Diseases  of  the  Stomach 412 

Special  Cures  in  the  Treatment  of  the  Diseases  of  the  Stomach               .  427 

Dysphagia 429 

Acute  Gastritis .      .                         .  429 

Chronic    Gastritis .      .                               .  430 

Atrophic  Catarrh  of  the  Stomach                             .  433 

Hypersecretion 435 

Dilatation  of  the   Stomach                        437 

Atony  of  the  Stomach   .      .            439 

Ulcer  of  the  Stomach    .                   442 

Hemorrhage    ...             461 

Carcinoma  463 

Gastroptosis  and  Enteroptosis                 .  465 

Nervous  Disorders ....  467 

Hyperchlorhydria  or  Hyperacidity 469 

Diet  in  Intestinal  Diseases 473 

Dyspepsia 477 

Acute  Catarrh                              .  479 

Chronic  Catarrh 479 

Dysentery                          482 

Ulcers 483 

Malignant    Growths 484 

Acute   Intestinal  Obstruction 484 

Chronic  Intestinal   Obstruction 484 

Appendicitis          .      .            484 

Mucomembranous  Catarrh 485 

Nervous    Affections 487 

Hemorrhoids         487 

Chronic  Diarrhea .  488 

Habitual    Constipation 490 

Chronic    Stasis 493 

Diet  in  Peritonitis              494 

Diet  in  Liver  Diseases 495 

Catarrhal  Jaundice 497 

Congestion 498 

Acute    Yellow    Atrophy 499 

Abscess 499 

Fatty    Liver        499 

Amyloid   Liver 499 

Syphilis 499 

Gall-stone  Disease 499 

Cirrhosis 502 

Diet  in  Diseases  of  the  Pancreas 503 

Diet  in  Diseases  of  the  Respiratory  Organs 504 

Pleurisy 504 

Empyema 504 

Laryngismus    Stridulus 505 

Laryngitis 505 

Asthma 505 

Emphysema 506 

Chronic    Bronchitis 507 

Hemorrhage  from   Lungs    .      .             507 

Pneumonia 507 

Diet  in  Diseases  of  the  Circulatory  System           510 

Diseases  of  the  Heart 510 

Heart  Lesions  in  Children 513 

Senile  Heart                   513 

Arteriosclerosis         516 

High   Blood-pressure 517 

Aneurysm                    517 

Angina  Pectoris 518 


14  CONTENTS        ^ 

Diet  IN  Disease  (Continued).  pagi 

Anemia .j 519 

Chlorosis < 521 

Leukemia ^-^■' 524 

Purpura   Haemorrhagica  524 

Hemophilia  524 

Diet  in  Diseases  of  the  Genitourinary  System 525 

Nephritis         539 

Acute  Nephritis 541 

Chronic  Parenchymatous  Nephritis 543 

Nephrosis 544 

Acute  Nephritis  due  to  Mercuric  Chlorid 545 

Chronic  Interstitial  Nephritis 545 , 

Floating  Kidney 548 

Amyloid  Kidney 548 

Pyelitis — Pyelonephritis 549 

Renal  and  Vesical  Calculi 549 

Lithemia— The  So-called  Uric-acid  Diathesis 549 

Gonorrhea 550 

Diet  in  Diseases  of  the  Nervous  System     ....  .  .  550 

Neuralgia 551 

Gastralgia 552 

Visceral  Neuralgia 552 

Migraine 553 

Insomnia  and  Disturbed  Sleep 553 

Vertigo 554 

Epilepsy    . 554 

Chorea 655 

Apoplexy  .      .  555 

Diet  in  Various  Toxic  Conditions 556 

Chronic  Morphin-poisoning 556 

Alcoholism 556 

Chronic  Lead-poisoning 557 

Weir-Mitchell  Rest  Cure  .  557 

Diet  for  the  Insane 565 

Diseases  in  which  Diet  is  a  Primary  Factor 567 

Diabetes 567 

Diabetes  Mellitus — The  Accessory  Diet  of  Foods  Rich  In  Carbohydrates  573 

Substitutes  for  Sugar 595 

Substitutes  for  Bread .,     .  596 

Gout  and  Goutiness 630 

Rheumatoid  Arthritis  (Athritis  Deformans) 640 

Obesity 640 

Diet  for  Leanness 659 

The  Deficiency  Diseases — Vitamins 659 

Scorbutus  or  Scurvy 664 

Beri-Beri  or  Kakke 666 

Pellagra  (Maidismus) 668 

Unclassified  Diseases 670 

Acidosis 670 

Cancer  and  Demineralized  Food 673 

Ductless  Glands,  Tumors  and  Diet 676 

Exophthalmic  Goiter 677 

Addison's  Disease 677 

Osteomalacia  .  677 

Diet  in  Diseases  of  the  Skin 678 

Eczema 679 

Urticaria 681 

Acne 681 

Acne  Rosacea 681 

Psoriasis 682 

Pruritus 682 

Furunculosis 882 


COyTENTS  15 

PAGE 

Special  Diets 683 

Karell  Diet  or  Milk  Cure 683 

Whey   Cure    ... 685 

Kumiss  Cure  685 

Buttermilk  Cure 685 

Yolk    Cure      .  686 

Diet  Cures     ■ .      .  686 

fcalt-free  Diet 688 

The  Dietetic  Management  of  Surgicax  Cases 699 

Diet  After  Operation 703 

Aemt  AMD  Navy  Rations 710 

Army  Rations 710 

Rations  of  Foreign  Armies 723 

Remarks 724 

Navy  Rations 725 

The  General  Mess 728 

The  Commissary  Store 730 

The  Preparation  of  Food 732 

Dietaries  in  Public  Institutions 734 

Prison  Dietaries 735 

Hospital   Dietaries 747 

The  Johns  Hopkins  Hospital 748 

Lakeside  Hospital,  Cleveland,  Ohio 749 

Full  Diet-table — Navy  Hospitals 752 

Craig  Colony  of  Epileptics 755 

Diet  for  Chorister  Boys  in  St.  Paul's  School,  Baltimore 756 

Tuberculosis  Infirmary,  Metropolitan  Hospital,  Blackwell's  Island  .      .  756 

Tuberculosis  Infirmary 756 

Second  Hospital  for  the  Insane  of  Maryland  for  the  Month  of  April  .  757 

United  States  Government  Hospital  for  the  Insane,  Washington,  D.  C.  758 

United  States  Government  Hospital  for  the  Insane,  St.  Elizabeth,  D.  C.  759 

Bay  View  Asylum    ...            761 

Robert  Garrett  Free  Hospital  for  Children,  Baltimore 763 

Children's   Hospital  of  Boston 764 

Great  Ormond  Street  Hospital  for  Sick  Children,  London     ....  766 

Recipes 768 

Beverages 768 

Cereal  and  Cereal  Gruels 770 

Length  of  Time  to  Cook  Cereals 771 

Bread         773 

Vegetables 775 

Time-table  for  Cooking  Vegetables  in  Water 775 

General  Rules  for  Cooking  Vegetables 775 

Soups  Without  Meat 776 

Milk  Preparations 777 

Eggs        781 

Eggs  and  Milk    .  782 

Meats 782 

General  Rules  for  Soups 784 

Methods  of  Preparing  Raw  Beef 788 

Meat  Jellies  Without  Gelatin 789 

Recipes  for  Foods  for  Diabetics  .      .  791 

The  Chemical  Composition  of  American  Food-matebials     ....   802 

Explanation  of  Terms 802 

Cuts  of  Meat ...   805 


16  CONTENTS 

PAGE 

Rapid  Reference  Diet-lists 837 

Fever 839 

Dyspepsia  and  Chronic  Gastritis 839 

Dilatation  of  the  Stomach 839 

Atony  of  the  Stomach 840 

Hyperchlorhydria  or  Hyperacidity 840 

Ulcer  of  the  Stomach " 841 

Chronic  Diarrhea 842 

Chronic  Constipation 842 

Debility  and  Anemia 843 

Obesity 843 

Diabetes 844 

Gout  and  Goutiness     ...            844 

Albuminuria       . 845 

Tuberculosis 845 

Epilepsy 846 

Diet   After  Normal   Confinement      ....            846 

Sample  Pamphlet  of  Information  for  Distribution  Among  the  Poor  in 

Summer 847 

Weights  and  Measures 849 

Locke's  Tables  of  Food  Values .  851 

Table  Equivalents  (Approximate) 851 

Appendix 883 

War  Dieting 883 


Index 887 


DIET  IN  HEALTH  AND  DISEASE 


THE  CHEMISTRY  AND  PHYSIOLOGY 
OF  DIGESTION 

Food  is  the  matter  that  is  taken  into  the  body  to  supply  nourish- 
ment or  to  replace  tissue-waste.  Every  physical  act  consumes  a  part 
of  the  force  that  has  been  derived  from  food.  The  maintenance  of 
the  body-heat  consumes  another  part,  and  in  growing  individuals  a 
certain  amount  is  utilized  in  building  up  the  new  tissues. 

Food  as  it  is  taken  into  the  body  differs  very  much  in  composition 
from  the  material  that  can  be  utilized  in  cell-growth  and  in  replacing 
the  tissue-waste.  The  function  of  digestion  is  so  to  alter  the  food  that 
it  maj'^  be  absorbed  by  the  blood,  and  prepare  it  for  assimilation  and 
utilization  by  the  various  tissues.  The  food  of  mankind  is  most  varied 
in  nature,  differing  with  the  seasons,  and  with  climates,  races  and 
countries. 

The  study  of  foods  is  a  most  complex  one,  and  until  recently  few  sci- 
entific investigations  along  this  line  had  been  made.  Fortunately, 
however,  experiments  are  now  being  carried  on  the  world  over,  and 
it  is  to  be  hoped  that  the  subject  of  diet  in  health  and  in  disease  will 
soon  be  lifted  out  of  the  vale  of  empiricism  where  it  has  so  long  rested. 

Water. — Water  enters  into  the  composition  of  every  tissue  in  the 
body  and  forms  more  than  60  per  cent,  of  the  entire  body-weight  of 
a  full-grown  man.  As  it  is  not  burned  up  in  the  metabolic  processes, 
it  does  not  furnish  any  energy. 

Salts. — The  earthy  salts,  which  form  about  6  per  cent,  of  the 
body-weight  of  an  adult  man,  furnish  little  if  any  energy.  They  are 
most  abundant  in  the  bones  and  teeth,  but  they  also  enter  into  the 
composition  of  other  tissues  and  fluids  of  the  body.  The  principal 
salts  of  the  body  are  calcium  phosphate  and  the  various  compounds 
of  potassium,  sodium,  magnesium,  and  iron.  The  mineral  salts  are 
very  necessary  to  life  and  health. 

Proteins. — These  are  substances  which  contain  nitrogen,  are  es- 
sential to  life,  and  are  regarded  as  combinations  of  the  various  amino- 
acids.  In  addition  to  carbon,  hydrogen,  oxygen,  and  nitrogen  protein 
generally  contains  sulphur  and  some  of  them  phosphorus,  iron,  cop- 
per, iodine,  manganese  and  zinc. 

The  proteins  are  variously  classified  and  two  elassfications,  based  on 
2  17 


18  CHEMISTRY  AND  PHYSIOLOGY  OF  DIGESTION 

the  solubility,  have  been  suggested,  one  by  the  English  Society  of 
Physiologists  and  one  by  the  American  Society  of  Biochemists. 

Americcm  Classification  of  Proteins. 

albumins 

I.     Simple    proteins     (proteins    which    yield    only    as  globulins 

amino-acids  or  their  derivatives  on  hydrolysis ) .  glutelins 

alcohol  soluble 

proteins    (prolamines) 

albuminoids 

histons 

protamins 

glycoproteins 
II.     Conjugated  proteins   (substances  which  contain  the  nucleoproteins 
protein  molecule  united  to  some  other  molecule  hemoglobins 
or  molecules  otherwise  than  salt).  phosphoproteins 

leucoproteins 

Primary  protein  derivatives  (formed  through  hy-      proteins 
drolytic  changes  which  cause  only  slight  altera-  metaproteins 
tions  of  the  protein  molecule ) .  coagulated 

proteins 

III.     Derived  Proteins. 

Secondary     protein     derivatives      (products     of  proteoses 

further     hydrolytic    clearage    of    the    protein  peptones 

molecule ) .  peptids 

Proteins  are  essential  to  life  and  the  body  is  constantly  metabolizing 
it,  whether  any  is  being  taken  in  or  not.  In  ordinary  life  the  body  is 
in  protein  (or  nitrogen)  equilibrium  and  as  much  protein  as  is  in- 
gested is  metabolized.  It  is  difficult  to  get  a  positive  nitrogen  balance, 
except  after  prolonged  fasting  or  after  recovery  from  wasting  dis- 
eases or  during  the  period  of  body  growth.  A  negative  nitrogen 
balance  is  seen  in  starvation  where  more  is  used  up  than  is  taken  in 
and  in  all  wasting  diseases,  such  as  tuberculosis,  in  fevers,  and  hyper- 
thyroidism. In  pathological  states  such  as  nephritis  there  may  be 
retention  of  nitrogen  compounds  in  the  body  due  to  the  failure  of  the 
kidney  to  excrete  them,  and  if  the  amount  exceeds  a  certain  amount 
a  condition  of  poisoning  and  uremia  is  brought  about. 

Protein  Sparers. — A  certain  amount  of  protein  is  essential,  but 
nitrogen  equilibrium  may  be  established  at  various  levels  and  if  but 
little  is  taken  in  the  protein  metabolized  for  heat  and  energy  may  be 
replaced  in  whole  or  part  by  fat  or  carbohydrate  foods  which  are  re- 
garded in  this  sense  as  protein  sparers.  Alcohol  also  acts  as  a  protein 
sparer. 

Protein  is  metabolized  by  oxidation  processes  into  chiefly  urea,  am- 
monia, carbon-dioxid  and  water.  The  intermediary  metabolism  is 
important  and  the  polypeptids,  the  amino-acids  and  the  nitrogen  free 
residues  of  the  deaminized  amino-acids  are  the  important  substances. 
The  proteins  are  absorbed  as  amino-acids.     (See  same.) 


DIGESTION  AND  ABSORPiION  19 

Superior  and  Inferior  Food  Proteins. — Some  food  proteins  are 
better  suited  for  human  food  than  others,  because  when  broken  up 
into  their  elementary  parts  or  amino-acids  more  of  these  can  be  util- 
ized in  forming  the  various  body  tissues  than  those  derived  from  other 
foods.  For  this  reason  the  proteins  of  milk,  meat,  eggs  and  fish  are 
most  valuable,  those  of  rice  and  potatoes  next  in  value,  while  those  of 
wheat,  maize  and  beans  are  distinctly  inferior. 

Thomas  has  shown  that  the  relative  value  of  these  proteins  are  as 
follows : 

Meat  protein   30  grams 

Milk  protein   31 

Rice  protein    34 

Potato  protein    38 

Bean   protein    54 

Bread  protein 76 

Maize  protein   102 

Thus  it  is  plain  that  the  vegetable' proteins  are  not  as  suitable  for 
repairing  tissue  waste,  although  if  sufficient  amounts  are  taken  life 
may  be  maintained. 

Casein  contains  all  the  amino-acids  necessary  for  growth  of  human 
tissues,  except  glycocoll,  but  the  human  body  can  make  glycocoll  from 
casein.  The  inferior  proteins  may  be  used  to  furnish  heat  and  form 
ammonia  and  urea  and  the  other  parts  are  easily  oxidized  until  the 
end  products  are  water  and  carbon  dioxid. 

Carbohydrates. — Carbohydrate  is  a  name  applied  to  compounds  of 
carbon,  hydrogen,  and  oxygen  as  they  occur  in  plants  and  animals 
and  the  name  is  used  because  most,  not  all,  contain  their  hydrogen 
and  oxygen  in  the  same  proportion  as  it  is  found  in  water,  that  is, 
two  of  hydrogen  to  one  of  oxygen.  Some  substances  with  the  same 
proportions  are  not  carbohydrates,  as  lactic  acid  C,.  Ho  0  or  acetic 
acid  Co  H4  O2.  The  chemical  properties  are  perhaps  more  character- 
istic. They  are,  at  least  the  simpler  ones,  reducing  agents,  that  is, 
they  give  up  their  oxygen  readily.  They  have  a  neutral  reaction  in 
aqueous  solution,  but  possess  weakly  acid  and  basic  characters.  They 
may  be  classified  at  present  as  follows : 

Monossiech&Yiis.—Levulose  or  Fructose. — This  is  one  of  the  sweetest 
sugars  and  is  found  in  nature  in  fruits  and  as  a  constituent  of  various 
di-  and  polysaccharides.  Thus  it  is  found  in  sucrose,  melitose,  lupeose 
and  inulin.  It  may  be  prepared  by  the  hydrolysis  of  cane  sugar  by 
sulphuric  acid  and  when  pure  occurs  in  white  needle-like  crystals  or 
in  a  dense  mass  which  becomes  light  yellow  on  standing,  especially 
if  exposed  to  light. 

Dextrose,  d-glucose  or  grape  sugar. — This  is  the  result  of  the  action 
of  dilute  acids  on  starch  and  forms  the  principal  part  of  commercial 
glucose.  It  is  found  in  cane  sugar,  in  fruits,  in  the  sap  of  plants 
and  in  the  blood  of  many  animals.     Commercial   glucose   or   corn 


20 


CHEMISTRY  AND  PHYSIOLOGY  OF  DIGESTION 


Cabbohydbates  - 


I.     Monosaccharids  ' 


II.  Disaccharids 


III.   Polysaccharids 


1.  Bioses. 

2.  Trioses. 

3.  Tetroses. 

4.  Pentoses. 

5.  Hexoses. 


Aldose. 

[  Aldoses. 
I  Ketoses. 

I  Aldoses. 
I  Ketoses. 


Aldoses. 
Ketoses. 

Aldoses. 
Ketoses. 

Aldose. 


Gly  col- 
aldehyde. 

Glycerose. 
Dioxyace- 
tone. 

Ery  those. 

d-Erythru- 

lose. 

Arabinose, 

xylose, 

ribose. 

l-Arabin- 

ulose. 

Dextrose, 
galactose, 
mannose. 
Levulose, 
sorbose. 


d-Manno- 
heptose. 


6.  Heptoses. 

1.  Lactose.  ( Glucose  +  galactose. ) 

2.  Maltose.  (Glucose  +  glucose.) 

3.  Saccharose.  (Glucose  +  levulose.) 

4.  Trehalose.  (Glucose  +  glucose.) 

5.  Melibiose.  (Galactose  +  glucose.) 


1.  Trisaccharids. 


2.  Tetrasaccharids. 


Colloidal   polysaccharids. 


Melitose  (RaflB- 
nose)  in  molasse. 
Melizitose.  (Pi- 
nus  larix. ) 
(Levulose  +  glu- 
cose +  galactose. 

Lupeose  in  peas; 
stachyose  ( Lup- 
eose consists  of 
two  molecules  of 
galactose,  one  of 
glucose,  and  one 
of  levulose.) 

f  Dextrins. 

Glycogen. 

Cellulose. 

Starch. 

Mucilages. 

Gums. 
.Inulin. 


syrup  is  usually  made  by  tlie  action  of  dilute  hydrochloric  acid  on 
corn  starch  or  on  potato  starch.  It  usually  contains  an  admixture 
of  dextrins  and  not  infrequently  impurities.  In  former  times  when 
it  was  largely  made  by  using  sulphuric  acid,  arsenical  poisoning  re- 


DIGESTION  AND  ABSORPTION 


21 


haride.                                              Occurrence. 

Yield  on 
hydrolysis. 

(Sucrose)          Sugar  cane;  beets 
(Saccharose)        (Saccharum  officinarum) 

Levulose 
Dextrose 

Germinating  barley 
Digestion  of  starch 

Dextrose 
Dextrose 

Milk 

Dextrose 
Galactose 

Various  fungi.     Boletus  edulis. 
Ergot.    Trehala 

Dextrose 
Dextrose 

From  melitose  in  molasses 
Australian  manna 

Galactose 
Dextrose 

suited  from  the  acid  containing  arsenic.  In  these  cases  the  glucose 
was  used  to  make  beer  which  contained  arsenic. 

d-Galactose. — This  is  found  as  one  of  the  constituents  of  milk-sugar 
or  lactose,  the  other  being  glucose.  It  is  found  in  nerve  sheaths  and 
on  the  brain  and  in  plants. 

Glucosides. — These  are  found  in  plants  and  animals  and  on  hydro- 
lysis form  glucose  or  some  other  monosaccharide. 

Disaccharids. — These  yield  two  molecules  of  monosaccharids  on 
hydrolysis  as  follows : 


Cane  sugar. 


Maltose 


Lactose 


Trehalose 


Melibose 


(See  also  under  heading  of  sugar.) 

Lactose. — This  is  found  in  the  mammary  gland  and  is  found  in 
milk.  It  is  not  as  sweet  as  cane  sugar.  Commercial  milk  sugar  con- 
tains many  impurities,  so  that  only  the  refined  product  is  suitable  for 
infant  feeding. 

Maltose. — This  is  found  most  widely  in  nature,  both  in  plants  and 
animals,  as  it  is  formed  by  the  action  of  amylase  in  starch.  It  crystal- 
lizes in  white  needles,  is  not  as  sweet  as  cane  sugar  and  ferments 
readily.  It  seems  possible  that  maltose  may  be  utilized  strictly  by 
the  tissues  and  it  has  been  suggested  for  use  in  feeding,  especially 
infants  and  invalids  under  certain  conditions. 

Polysaccharides. — These  are  either  insoluble  or  form  colloids  in 
aqueous  solutions  and  are  represented  by  starch,  glycogen,  dextrins, 
cellulose,  various  gums,  mucilage,  and  inulin. 

Glucose  Tolerance. — Woodyatt,  Sansum  and  Wilder  have  de- 
termined that  a  man  weighing  70  kilograms  when  resting  quietly  in 
bed  may  receive  and  utilize  63  grams  of  glucose  by  vein  per  hour. 
This  amounts  to  252  calories  per  hour  or  6,048  per  day  or  over  double 
his  requirements.  The  normal  tolerance  limit  is  near  0.85  grams 
glucose  per  kilo  of  body  weight  hourly,  which  corresponds  to  the 
figures  of  Blumenthal  determined  on  animals.  In  Graves'  disease 
the  tolerance  limit  was  0.65  grams  per  kilo  an  hour.  (See  also 
Wilder  and  Sansum,  The  Archives  of  Internal  Medicine,  1917,  xix, 
page  311.) 

Levulose  tolerance  is  0.15  grams  per  kilo  an  hour,  galactose  0.1 


%%  CHEMISTRY  AXD  PHYSIOLOGY  OF  DIGESTION 

grams  and  lactose  approaches  0.  When  glucose  is  given  faster  than 
the  tolerance  it  causes  glycosuria  and  diuresis.  If  the  amounts  given 
are  much  in  excess  of  the  tolerance  the  diuresis  is  remarkable  and 
may  lead  to  dehydration  and  if  continued  enormous  quantities  of 
fluid  may  be  required  which  may  lead  to  heart  failure. 

By  mouth  the  amounts  of  the  various  sugars  necessary  to  produce 
glycosuria  are  given  by  Von  Noorden  as  follows: 

Milk  sugar,  more  than  120  grams. 

Cane  sugar,  more  than  150  to  200  grams. 

Fruit  sugar,  more  than  200  grams. 

Grape  sugar,  more  than  200  to  250  grams. 

Glycogen. — One  of  the  most  important  functions  of  the  liver  is 
the  so-called  glycogenic  function.  In  1857  Claude  Bernard  demon- 
strated the  presence  of  glycogen  and  formulated  a  classical  theory 
regarding  its  place  in  nutrition.  Glycogen  is  soluble  in  water  and 
has  the  same  chemic  formula  as  starch.  Toward  digestive  juices  it 
also  behaves  like  starch  and  the  end  products  are  the  same  as  in 
the  case  of  starch,  namely,  maltose  and  dextrose.  It  is  commonly 
known  as  animal  starch.  With  iodin  it  gives  a  reddish  instead  of  a 
blue  color  as  obtained  with  ordinary  starch.  Glycogen  is  formed 
synthetically  in  the  liver  from  the  monosaceharids  by  the  process  of 
splitting  off  one  molecule  of  water.  It  is  then  stored  in  the  liver 
cells.  The  muscles  also  act  as  a  store-house  for  glycogen.  Lactose 
must  first  be  split  into  dextrose  and  galactose  in  the  intestine  before 
it  may  be  transformed  into  glycogen  and  advantage  is  taken  of  this 
fact  in  using  lactose  in  a  test  for  renal  function  by  injecting  it 
directly  into  the  blood.  There  are  several  theories  regarding  the  way 
glycogen  is  used.  Bernard  thought  the  liver  acted  as  a  store-house 
and  regulator,  the  glycogen  being  converted  into  dextrose  and  con- 
veyed to  the  muscles  through  the  blood.  If  the  amount  of  sugar  in 
the  blood  exceeds  a  certain  percentage  it  is  excreted  by  the  kidneys. 
A  special  enzyme,  called  glycogenase,  has  been  described  in  the  liver 
as  the  active  agent  in  causing  the  transformation.  Pavy  believes 
that  the  carbohydrate  molecule  is  fastened  on  to  the  protein  molecule 
in  the  liver  and  thus  conveyed  to  the  muscles  where  it  is  set  free.  In 
starvation  the  glycogen  part  of  the  liver  is  first  used  up  and  the 
muscles  are  found  to  contain  a  considerable  amount,  even  after  the 
liver  has  become  glycogen-free.  The  difference  that  exists  between 
the  muscles  and  liver  supplies  of  glycogen  have  been  compared  to  the 
difference  between  retail  shops  where  the  material  is  supplied  imme- 
diateh^  to  the  consumer,"  and  the  warehouse  where  it  is  stored  in  large 
quantities. 

Glycogen  may  also  be  formed  from  the  proteins  of  the  body  as  has 
been  proven  experimentally.  This  occurs  pathologically  in  diabetes. 
Fats  may  also  apparently  be  converted  into  glycogen,  but  there  is  a 
question  as  to  how  far  this  actually  occurs  in  the  human  body  and 


DIGESTION  AND  ABSORPTION  23 

some  believe  that  it  only  takes  place  under  certain  pathological  con- 
ditions. 

Fats  and  Allied  Substances. — There  is  a  group  of  substances 
popularly  called  fats,  a  term  which  refers  more  particularly  to  one 
member  of  the  group  which  includes  fats,  oils,  waxes,  phosphatids, 
sterols  and  a  few  other  substances.  It  has  been  suggested  that  the 
whole  lot  be  called  lipins.  They  have  in  common  certain  properties, 
they  are  greasy,  insoluble  in  water,  soluble  in  chloroform,  alcohol, 
ether  and  other  fat  solvents.  Fat  enters  into  the  composition  of 
protoplasm  and  enables  it  to  take  up  water  without'  dissolving.  The 
fats  of  the  body  are  esters  of  glycerin  (called  by  some  authors 
glycerol).  Glycerin  is  a  triatomic  alcohol  and  all  those  of  the 
hydroxyl  groups  are  replaced  by  acid  radicals,  palmitic,  stearic  and 
oleic  acids  as  a  rule,  but  others  as  butyric  acid  occur.  Fats  are 
sometimes  referred  to  as  triglycerids.  Fats,  in  a  limited  sense,  are 
esters  of  glycerin  and  fatty  acids,  which  are  solid  at  20°  C.  Dif- 
ferent fats  vary  in  their  melting  point.  Body  fat  is  a  mixture  of 
stearin,  palmitin  and  olein  and  its  melting  point  is  25°  C.  Olein  has 
a  melting  point  of  5°  C,  palmitin  45°  C,  and  stearin  varies  from 
53°  to  65°  C. 

Fatty  oils  are  neutral  esters  of  gh'cerin  and  fatty  acids,  liquid  at 
20°  C.  These  are  divided  into  drying  oils,  as  linseed  oil,  which 
dries  and  hardens  on  exposure  to  light  and  air;  semi-drying  oils,  as 
cottonseed  oil.  which  thickens  gradually  on  exposure ;  non-drying  oils, 
as  olive  oil,  which  neither  dries  nor  thickens;  and  essential  oils,  as 
oil  of  cloves,  which  are  generally  volatile  and  odiferous. 

The  Metabolism  of  Fat. — The  fat  is  utilized  in  the  body  to  build 
up  the  fatty  tissues  and  it  enters  very  largely  in  the  composition  of 
the  red  bone  marrow.  It  is  also  used  in  the  formation  of  protoplasm. 
The  fats  are  oxidized  until  they  are  reduced  to  carbon  dioxid  and 
water,  but  the  intermediate  changes  that  take  place  are  not  very  well 
understood  at  this  time.  The  long  carbon  chains  of  the  higher 
fatty  acids  are  broken  down  by  oxidation. 

Some  of  the  fats  may  form  sugar,  as  in  diabetes,  but  the  changes 
by  which  this  is  possible  are  not  understood. 

Fats  are  also  transformed  into  the  important  phosphatids,  as  leci- 
thin and  eerebrin,  into  cholesterin  and  the  bile  acids. 

Foreign  fats  may  be  absorbed  as  such  and  be  deposited  in  the 
body  as  such  and  apparently  utilized  by  the  body  in  the  same  way  as 
ordinary  fat.  It  is  believed  that  fatty  tissue  derived  from  mutton 
is  firmer  and  more  resistant  than  that  formed  from  the  oils. 

Part  of  the  fats  of  the  body  are  derived  from  the  transformation  of 
carbohydrates.  Thus  carbohydrates  contain  more  oxygen  and  it  has 
been  suggested  that  after  part  of  the  oxygen  has  been  used  the  re- 
maining carbon  compounds  form  fatty  acids. 

Part  of  the  fat   is   also   formed   from   protein.     This   fat   is   the 


24  CHEMISTRY  AND  PHYSIOLOGY  OF  DIGESTION 

deaminized  residue  of  the  amino-acids  of  the  protein.  These  may 
also  form  sugar. 

Apart  from  fats  stored  up  as  such  lipins  make  up  varying  amounts 
of  the  animal  body,  the  greatest  amounts  being  in  the  brain  and 
adrenal. 

Fats  and  oils  contain  less  oxygen  in  proportion  to  their  carbon 
content  as  compared  to  carbohydrates.  Fats  are  solid  at  ordinary 
temperatures,  whilst  oils  are  fluid.  The  fatty  acids  of  the  fats  are 
nearly  or  totally  saturated  while  those  of  the  oils  are  not.  It  is 
interesting  from  a  food  standpoint  to  note  that  not  all  fats  are  the 
same  in  their  relation  to  the  growth  of  young  animals.  Certain  fats 
evidently  contain  vitamines  whilst  others  do  not.  Thus  they  are 
present  in  butter  and  absent  in  olive  oil.  Mendel  and  Osborne  found 
that  young  rats  did  not  grow  as  rapidly  when  fed  on  oleomargarine 
or  butterine  as  when  fed  on  butter. 

DIGESTION  AND  ABSORPTION 

DIGESTION 

Food,  in  order  to  be  used  by  the  body,  must  be  digested  and  this 
process  of  digestion  is  a  complicated  one.  It  might  almost  be  said 
to  begin  before  the  food  is  eaten,  as  it  is  greatly  influenced  by  appe- 
tite, smell,  sight,  and  the  surroundings.  These  subjects  will  be  men- 
tioned more  fully  later  on.  Good  food  prepared  in  a  skilful  manner, 
pleasant  to  see,  to  smell,  and  to  taste,  taken  in  comfortable  surround- 
ings, with  cheerful  companions,  will  be  digested  with  ease  by  normal 
individuals,  while  the  reverse  of  all  or  any  of  these  may  cause 
indigestion  due  to  the  mental  action  upon  digestion — chiefly,  perhaps, 
on  the  digestive  glands.  Pawlow  has  made  a  most  fascinating  study 
of  this  subject,  to  which  the  reader  is  referred.^ 

The  Passage  of  Food  Through  the  Alimentary  Tract. — The  first 
step  in  the  digestion  of  food  is  mastication,  which  is  perhaps  the 
only  purely  voluntary  act  connected  with  the  process.  By  this  means 
the  food  is  ground  to  a  fine  pulp  and  thoroughly  mixed  with  saliva. 
It  is  necessary  to  have  good  teeth,  and  the  importance  of  the  care 
and  preservation  of  the  teeth  cannot  be  too  strongly  insisted  upon. 
Defective  teeth  are  a  menace  to  health,  as  they  lead  to  the  food  being 
imperfectly  masticated,  and  the  constant  absorption  of  toxic  material 
may  affect  both  digestion  and  the  general  health.  In  the  process  of 
chewing  the  muscles  of  the  cheeks  and  lips  serve  to  keep  the  food  in 
the  line  of  the  teeth,  and  when  the  facial  muscles  are  paralyzed  masti- 
cation may  be  difficult. 

Deglutition  is  usually  a  reflex  action  and  is  generally  involuntary, 
although  it  may  be  begun  by  a  voluntary  effort.  The  food  passes 
with  varied  rapidity  from  the  mouth  through  the  pharynx  and  esoph- 
1  Pawlow,  The  Work  of  the  Digestive  Glands. 


DIGESTION  AND  ABSORPTION  25 

agus  into  the  stomach.  To  be  easily  swallowed  the  food  must  be 
moist  and  on  the  tongue,  and  it  is  difficult  or  impossible  to  swallow 
dry  food.  Liquid  or  very  soft  food  may  pass  directly  into  the 
stomach  in  as  little  as  0.1  second,  but  semisolid  and  solid  food  are 
forced  down  the  esophagus  by  a  sort  of  peristaltic  movement,  taking 
as  long  as  six  seconds  to  reach  the  stomach.  There  may  be  a  delay 
of  from  four  to  eight  seconds  at  the  cardiac  sphincter.  Paraly- 
sis of  the  soft  palate  causes  the  food  to  be  regurgitated  through 
the  nose  when  swallowing  is  attempted,  and  if  the  muscles  of  the 
pharynx  or  larynx  are  paralyzed  the  food  may  be  aspirated 
into  the  trachea,  bronchi,  or  lung,  and  so  set  up  a  bronchopneu- 
monia. 

Food  remains  in  the  stomach  until  it  has  been  reduced  to  more  or 
less  of  a  liquid,  when  it  is  forced  through  the  pylorus  from  time  to 
time.  Our  knowledge  of  gastric  movements  dates  from  the  classic 
experiments  made  on  Alexis  St.  Martin  by  Beaumont,  and  a  great 
deal  of  research  has  been  devoted  to  the  subject  in  recent  years. 
The  fundus  of  the  stomach  acts  as  a  reservoir  for  the  food,  while 
the  pyloric  end  serves  to  grind  and  macerate  it  until  it  is  forced  out 
of  the  stomach  into  the  duodenum,  the  pylorus  apparently  opening 
under  the  stimulus  caused  by  the  combination  of  the  food  being 
liquid  in  character  and  acid  in  reaction.  In  the  duodenum  the  acid 
causes  the  pylorus  to  close.  The  order  in  which  the  food  is  digested 
depends  somewhat  on  the  order  in  which  it  is  ingested  and  the  amount 
of  fluid  taken  with  it.  For  example,  if  carbohydrates  are  fed  first  and 
then  proteins,  the  carbohydrate  passes  almost  immediately  into  the 
small  intestine ;  if,  however,  the  protein  is  fed  first,  the  carbohydrate 
remains  in  the  stomach  much  longer. 

Hedbloom  and  Cannon  have  summarized  the  results  of  their  inves- 
tigations on  the  passage  of  food  from  the  stomach  as  follows : 

If  carbohydrate  food  is  thinned  by  adding  water,  there  is,  within 
limits,  very  little  change  in  the  rate  of  exit  from  the  stomach ;  but 
adding  water  to  protein  food  tends  to  make  the  discharge  more  rapid. 
When  hard  particles  are  present  in  the  food,  the  rate  of  outgo  from 
the  stomach  is  notably  retarded.  Coarse,  branny  food  leaves  the 
stomach  slightly  faster  than  similar  foods  of  finer  texture.  The  pres- 
ence of  gas  in  the  stomach  delays  gastric  discharge,  an  effect  due  to 
the  gas  preventing  the  walls  of  the  stomach  from  exerting  the  normal 
mixing  and  propelling  action  on  the  food.  No  considerable  variation 
from  the  normal  rate  of  exit  from  the  stomach  is  observed  when  the 
food  is  fed  very  hot  or  very  cold.  Food  with  approximately  normal 
acidity  leaves  the  stomach  much  faster  than  food  which  is  hyperacid 
(1  per  cent.),  a  result  in  harmony  with  other  observations  on  the 
acid  control  of  the  pylorus.  Feeding  acid  food  is  followed  by  deep 
and  rapid  peristalsis.  Massage  of  the  stomach,  even  when  extensive, 
has  very  slight  influence  on  the  passage  of  food  through  the  pylorus. 


26  chjEMIstry  and  physiology  of  digestion 

Irritation  of  the  colon  (with  croton  oil)  notably  retards  gastric  dis- 
charge, and  delays  the  movements  of  food  through  the  small  intes- 
tine. 

In  the  intestine  the  food  is  moved  forward  by  the  peristaltic  move- 
ments; a  wave  of  relaxation  moves  along  the  intestine  followed  by  a 
wave  of  contraction  and  this  serves  to  pass  the  contents  of  the  bowel 
downward.  Antiperistalsis  is  said  not  to  occur  under  normal  condi- 
tions ;  it  ma}^  occur  in  injury  or  disease  of  the  intestine,  especially  in 
intestinal  obstruction.  In  addition  to  this  general  movement  there 
are  local  rhythmic  movements  occurring  at  the  parts  of  the  intestine 
occupied  by  food.  The  mass  to  be  digested  is  separated  into  numerous 
small  masses  by  this  movement,  and  then  these  are  swept  together  and 
also  onward  by  the  wave  of  peristalsis.  The  length  of  time  that  a 
meal  takes  to  pass  from  the  stomach  to  the  large  bowel  varies,  but  it 
is  about  four  hours  on  an  average,  and  the  first  part  of  the  meal  may 
be  at  the  ileocecal  valve  by  the  time  the  last  of  it  leaves  the  stomach. 
Various  things  may  upset  the  movements  of  the  intestines.  A  sudden 
disturbance  of  circulation  in  the  bowel  may  cause  violent  movements, 
and  dyspnea  may  either  increase  the  movements  or  stop  them  alto- 
gether. The  organic  acids  formed  in  the  bowel  as  the  result  of  the 
bacterial  action  act  as  stimulants  to  intestinal  movement. 

The  movement  through  the  large  intestine  is  slow,  as  it  is  there  that 
most  of  the  water  is  absorbed.  The  passage  of  the  intestinal  contents 
is  delayed  in  the  ascending  colon  by  reverse  peristaltic  movements. 
According  to  the  observations  of  Hertz  the  feces  take  two  hours  on 
an  average  to  pass  from  the  ileocecal  valve  to  the  hepatic  flexure,  and 
about  four  and  a  half  hours  to  pass  from  there  to  the  splenic  flexure, 
from  whence  the  feces  are  moved  slowly  to  the  sigmoid  flexure.  The 
rectum  is  probably  empty  until  just  before  defecation,  and  the  en- 
trance of  feces  into  the  rectum  probably  excites  the  desire.  The 
rectum  is  closed  by  the  internal  and  external  sphincters,  the  latter 
being  partly  under  the  control  of  the  will.  Defecation  is  partly  a 
voluntary  and  partly  an  involuntarj'  action. 

The  digestion  of  food  takes  place  through  a  number  of  chemical 
changes  brought  about  in  the  alimentary  tract  by  the  action  of  certain 
unorganized  ferments  usually  known  as  enzymes.  Along  with  these 
chemical  changes  there  are,  of  course,  alterations  in  the  physical 
properties  of  the  food,  the  two  combined  allowing  the  useful  part  to 
be  assimilated  while  the  remainder  passes  ot¥  as  refuse. 

Enzymes. — An  enzyme  is  a  substance,  produced  by  living  cells, 
which  acts  by  catalysis.  They  are  complex  nitrogenous  substances 
which  act  specifically,  the  exact  chemical  nature  of  which  is  unknown. 
Howell  makes  the  following  classification — 

1.  Proteolytic  or  protein-splitting  enzymes. — Examples: — Pepsin  of 
gastric  juice,  trypsin  of  pancreatic  juice.  They  cause  a  hydrolytic 
cleavage  of  the  protein  molecule. 


DIGESTION  AND  ABSORPTION  27 

2.  Amylolytic  or  starch-splitting  enzymes. — Examples: — Ptyalin  or 
salivary  diastase,  amylase,  or  pancreatic  diastase.  Their  action  is 
closely  similar  to  that  of  the  classical  enzyme  of  this  group — diastase 
— found  in  germinating  barley  grains.  They  cause  a  hydrolytic  cleav- 
age of  the  starch  molecule. 

3.  Lipolytic  or  fat-splitting  enzymes. — Examples : — The  lipase  found 
in  the  pancreatic  secretion,  in  the  liver,  connective  tissue,  blood,  etc. 
They  cause  hydrolytic  cleavage  of  the  fat  molecule. 

4.  The  deaminizing  enzymes,  which  by  hydrolytic  cleavage  split  off 
an  NH„  group  as  ammonia.  Thus  alanin  by  hydrolysis  loses  its 
NH„  group  as  ammonia  and  passes  into  lactic  acid. 

5.  Protective  enzymes. — Experimental  work  recently  has  shown 
that  when  foreign  proteins,  carbohj^drates,  or  fats  are  introduced  into 
the  blood  of  a  living  animal  corresponding  enzymes  are  formed  which 
are  adapted  to  break  down  the  foreign  material  by  a  process  of  diges- 
tion. 

6.  Sugar-splitting  enzymes,  or  those  having  the  property  of  con- 
verting the  double  into  the  single  sugars — the  disaccharids,  such  as 
sugar-cane  and  malto.se,  into  the  monosaccharids,  as  dextrose  and 
le\'Tilose.  Two  such  enzymes  are  found  in  the  small  intestine.  One 
of  these  acts  on  cane-sugar,  and  is  known  as  invertin  or  invertase; 
whereas  the  other  acts  on  maltose,  and  is  known  as  maltase.  Other 
enzymes  split  the  monosaccharids,  as  one  found  in  the  tissues  capable 
of  changing  the  blood  and  tissue  sugar  (dextrose)  into  lactic  acid. 

7.  Coagulating  enzymes,  or  those  acting  upon  soluble  proteins,  pre- 
cipitating them  in  an  insoluble  form.  Rennin,  the  milk-curdling  fer- 
ment of  the  gastric  juice,  is  an  example  of  this  class  of  enzymes. 

8.  Oxidizing  Enzymes  or  Oxidases. — These  set  up  oxidation  processes. 
They  are  found  in  the  various  organs  and  tissues.   (See  Table,  page  28.) 

Enzymes  have  certain  properties  in  common.  They  are,  for  ex- 
ample, soluble  in  water,  salt  solution  and  glycerin.  They  are  de- 
stroyed at  a  temperature  of  from  60°  to  80°  C,  and  their  action  is 
retarded  or  entirely  suspended  by  low  temperatures, — e.  g.,  by  freez- 
ing,— without,  however,  actually  destroying  the  enzyme.  They  are 
characterized  further  by  the  fact  that  after  a  certain  degree  of 
change  has  been  effected  the  products  of  their  activity  prevent  fur- 
ther action,  so  that  most  of  them  may  be  said  to  be  incomplete  in 
this  respect.  Most  enzymes  show  an  optimum  activity  at  temperatures 
approximating  that  of  the  body. 

Another  curious  fact  is  that  the  activity  of  an  enzyme  is  not  in 
proportion  to  the  amount  present.  A  trifling  quantity  may  effect 
enormous  change,  and  increasing  the  amount  of  enzyme  augments  the 
change  produced,  but  only  to  a  certain  point,  after  which  the  action 
is  the  same  whether  much  or  little  be  added.  An  enzyme  cannot  be 
used  over  and  over  again,  as  it  is  altered  in  some  way  and  so  rendered 
incapable  of  indefinite  action. 


28 


CHEMISTRY  AND  PHYSIOLOGY  OF  DIGESTION 


A  Partial  List  of  the  Enzymes  Concerned  i/n  the  Processes  of  Digestion  and 
Nutrition     ( Howell ) . 


Enzyme. 

Ptyalin  (salivary 

diastase) 
Amylase  (pancre- 
atic diastase) 

Liver  glj'cogenase 
Muscle  glycogenase 
Invertase 

Maltase 


Lactase 


Glycolytic  ? 


°  ^     Lipase  ( steapsin ) 


Where  chiefly  found. 
Salivary  secretion 

Pancreatic  secretion 

Liver 
Muscles 
Small  intestine 

Small  intestine, 
salivary    and    pancre- 
atic secretion 
Small  intestine 

Muscles  ? 


Action. 

Converts  starch  to  sugar 
( Maltose ) . 

Converts  starch  to  sugar 

( Maltose ) . 
Converts  glycogen  to   dextrose. 
Converts  glycogen   to   dextrose. 
Converts  cane  sugar  to  dextrose 

and  levulose. 
Converts  maltose  to  dextrose. 


Converts  lactose  to  dextrose  and 

galactose. 
Splits  and  oxidizes  dextrose. 


Pancreatic     secretion,    Splits    neutral    fats    to    fatty 
fat,  tissues,  blood,  etc.        acids   and   glycerin. 


Pepsin 

Trypsin 

Erepsin 


Gastric  juice 
Pancreatic  juice 
Small  intestine 


Group  of  autolytic    Tissues  generally 

enzymes. 

Guanase  Thymus,  adrenals, 

pancreas 
Adenase  Spleen,   pancreas, 

liver 
Deaminase?  Tissues  generally 


Oxidases 
Keductases 


Catalase 
Arginase 


Lungs,    liver,    muscle, 

etc. 

Tissues  generally 

Many  tissues 
Liver,  and  spleen 


Converts  proteins  to  peptones 
and  proteoses. 

Splits  proteins  into  their  con- 
stituent  amino-acids. 

Splits  peptones  and  proteose? 
into  their  constituent  amino- 
acids. 

Splits    proteins    into    nitrogen- 
ous bases  and  amino-bodies. 
Converts  guanin  to  xanthin. 

Converts    adenin    to   hypoxan- 

thin. 
Splits  off  the  XHo  group  from 

the    amino    acids    with    the 

formation  of  non  nitrogenous 

organic  acids. 

Causes  oxidation  of  organic 
substances. 

Cause  reduction  as  for  example, 
the  reduction  of  oxyhemoglo- 
bin   to    hemoglolnn. 

Decomposes  hydrogen  peroxide. 

Splits  arginin  with  production 
of  urea  and  ornithin. 


It  is  commonly  believed  that  enzymes  effect  their  changes  by  hydro- 
lysis; that  is,  they  cause  the  substance  acted  upon  to  take  up  one 
or  more  molecules  of  water,  the  result  being  that  the  complex  body 
separates  into  two  simpler  ones.  Take,  for  example,  the  familiar 
example  of  the  change  in  cane-sugar : 

C^H^^On  +  H,0  =  CeH^Oe  +  CeH^.Oe. 
Cane-sugar.  Dextrose.    Levulose. 

How  this  change  is  brought  about  is  not  known. 


DIGESTION  AND  ABSORPTION  29 

With  this  preliminary  consideration  of  the  enzymes  we  may  now 
proceed  to  the  study  of  digestion. 

Salivary  Digestion. — When  food  is  taken  into  the  mouth  and  mas- 
ticated, there  is  a  stimulation  of  the  secretory  nerves  which  results 
in  a  flow  of  saliva,  which  is  the  combined  secretion  of  the  parotid, 
submaxillary,  and  sublingual  glands,  together  with  that  of  the  mucous 
glands  of  the  mouth.  It  is  usually  colorless,  ropy,  and  stringy,  due 
to  the  presence  of  mucin,  of  a  weakly  alkaline  reaction,  and  has  a 
specific  gravit}^  of  1.003.  It  acts  best  in  a  weakly  alkaline  medium. 
The  digestive  ferment  which  it  contains  is  called  ptyalin.  Perhaps  the 
chief  use  of  saliva  is  to  soften  the  food  and  to  act  as  a  lubricant. 
The  thorough  moistening  of  the  food  ensures  its  being  easily  swal- 
lowed. The  amount  of  digestion  that  takes  place  in  the  mouth  is 
small,  owing  to  the  short  time  the  food  remains  there,  but  the  action 
of  the  saliva  is,  under  certain  conditions,  continued  in  the  stomach. 
Mastication  not  only  divides  the  food,  but  stimulates  the  flow  of 
saliva,  and  this  in  turn  moistens  the  food  and  permits  it  to  be  tasted. 
The  taste  of  food  further  stimulates  the  secretion  of  saliva. 

Ptyalin,  the  digestive  enzyme,  acts  upon  starches  by  a  hydrolytic 
cleavage  process,  converting  them  into  sugar  and  dextrin.  The  exact 
chemical  process  through  which  the  starch  molecule  goes  has  not  been 
definitely  decided  upon,  but  the  following  scheme  is  most  generally 
accepted : 

Starch  /         ^^'+^^®^     +  •        f         Maltose.  , ,,  , , 

\  Erythrodextrin      |  Achroodextrin.      {f^^^^Zl'. 

The  presence  of  starch  being  evidenced  by  its  blue  color  when  brought 
into  contact  with  iodin,  erythrodextrin  red,  and  achroodextrin  color- 
less. 

Until  late  years  it  was  thought  that  the  digestion  of  starches  in  the 
stomach  was  quite  insignificant,  because  of  the  fact  that  acid  not  only 
inhibits  but  destroys  ptyalin.  Since  the  a;-ray  work  of  such  investi- 
gators as  Cannon  and  Herz  we  know  this  conception  to  be  erroneous, 
as  they  have  shown  the  layer  formation  of  food  as  it  enters  the  stom- 
ach, whereby  the  last  to  be  received  is  protected  from  the  acid  secre- 
tion of  the  fundic  portion,  thus  delaying  for  a  considerable  time 
(forty  to  ninety  minutes)  the  contact  of  acid  with  ptyalin,  and  there- 
fore, salivary  digestion  is  carried  on  to  a  considerable  degree  before 
being  interfered  with  by  the  gastric  juice.  Raw  starch  is  acted  upon 
very  slowly,  whereas  in  well-cooked  starch  sugar  may  be  detected 
after  even  one  minute.  This  is  due  to  the  fact  that  the  starch  gran- 
ules are  surrounded  by  an  envelope  of  vegetable  fiber  (cellulose)  that 
protects  it  from  the  action  of  the  ferment.  On  boiling,  this  cellulose 
covering  is  broken,  and  the  starch  is  not  only  liberated,  but  also  takes 
up  water,  rendering  it  easy  of  digestion.     (See  section  on  Cooking.) 

Gastric    Digestion. — We    are    indebted    to    Pawlow    for    a    great 


30  CHEMISTRY  AND  PHYSIOLOGY  OF  DIGESTION 

amount  of  pioneer  work  concerning  the  nature  of  digestive  processes. 
It  was  he  who  established  the  fact  of  psychic  secretion,  which  we 
now  linow  to  be  a  most  important  factor  in  digestion.  The  hrst  stimu- 
lus of  gastric  secretion  originates  in  the  mouth,  and  this  causes  the 
first  flow  of  gastric  juice,  when  the  furtherance  of  the  flow  depends 
upon  the  action  of  what  we  know  as  secretagogues.  Some  foods  con- 
tain substances  that  have  the  power  to  cause  secretion  of  gastric 
juice  when  taken  into  the  stomach ;  for  example,  meat  extract  and 
meat  juices.  This  element  is  present  to  a  much  less  extent  in  milk, 
while  bread  and  white  of  egg  have  practically  no  effect  at  all. 

Howell  gives  three  steps  in  the  mechanism  of  secretion:  (1)  Psy- 
chical secretion;  (2)  Secretion  from  secretagogues  contained  in  the 
food;  (3)  The  secretion  from  secretagogues  contained  in  the  products 
of  digestion. 

Edkins  is  of  the  opinion  that  the  secretagogues,  whether  present 
in  the  food  or  formed  during  digestion,  act  upon  the  pyloric  mucous 
membrane  and  form  a  substance  which  he  designates  as  gastric  secre- 
tin, and  this  substance  after  absorption  into  the  blood  is  carried  to  the 
gastric  glands  and  stimulates  them  to  secretion. 

Various  foods  produce  gastric  secretion  of  varying  digestive  quali- 
ties; for  instance,  that  produced  by  bread  is  less  in  quantity  but  of 
greater  digestive  power  than  that  produced  by  meat.  The  juice 
produced  by  psychic  stimulation  is  always  of  the  same  quality. 

Gastric  juice  is  a  thin,  colorless,  strongly  acid  liquid,  with  a  specific 
gravity  of  about  1.002.  Its  most  important  constituents  are  hydro- 
chloric acid,  pepsin,  rennin,  and  lipase. 

Pepsin  is  a  proteolytic  enzyme  acting  only  in  acid  media.  It  is 
present  in  the  cells  as  a  zymogen,  and  is  not  changed  to  the  active 
pepsin  until  after  secretion.  The  process  of  peptic  digestion  is  usually 
accepted  as  follows: 

Protein. 

Acid  albumin  ( syntonin ) . 

Primary  proteoses    (protalbumoses) . 

Secondary  proteoses   (deutero-albumoses). 

Peptone. 

The  whole  process  seems  to  be  one  of  hydrolytic  cleavage  of  the 
protein  molecule,  with  peptone  as  the  final  stages  as  far  as  gastric 
digestion  is  concerned.  All  changes  wrought  by  the  digestive  fer- 
ments on  the  food-stuffs  are  hydrolytic.  Recently  it  has  been  stated 
that  if  time  enough  is  given  to  the  action  of  pepsin  it  will  break  the 
protein  molecule  as  completely  as  after  the  action  of  trypsin,  or  after 
hydrolysis  by  acids. 

Bennin  is  the  enzyme  of  the  gastric  juice  which  has  to  do  with  the 
curdling  of  milk.  It  is  present  in  the  cells  of  the  gastric  tubules  in 
the  form  of  a  zymogen,  being  converted  into  an  active  enzyme  in  the 


DIGESTION  AXD  ABSORPTION  31 

presence  of  acid.  The  action  upon  human  milk  causes  the  formation 
of  loose  flocculi,  while  the  curd  formed  by  its  action  on  cows'  milk  is 
more  solid  and  of  firmer  consistency. 

Fats  undergo  simply  a  physical  change  in  the  stomach,  the  chemical 
action  upon  them  being  effected  by  the  intestinal  juices. 

Intestinal  Digestion. — When  the  food  has  been  passed  into  the 
small  intestine,  it  is  acted  on  simultaneously  by  three  secretions — the 
pancreatic  juice,  the  intestinal  juice,  and  the  bile.  Although  these 
secretions,  as  stated,  act  together,  for  the  sake  of  simplicity  each  will 
be  considered  separately. 

Pancreatic  Juice. — Our  knowledge  of  the  functions  of  the  pancreatic 
juice  is  obtained  largely  from  experiments  made  on  the  lower  animals. 
In  man  it  enters  the  intestine  together  with  or  closely  following  or 
preceding  the  bile,  being  mixed  with  the  latter  secretion  and  the  food- 
material  at  the  same  time.  It  is  alkaline  in  reaction,  and  contains  at 
least  three,  and  probably  more,  enzymes — viz.,  trypsin,  amylase,  steap- 
sin,  or  lipase,  and,  it  is  said,  a  milk-curdling  ferment  similar  to 
rennin. 

According  to  Pawlow,  the  amounts  of  the  various  ferments  in 
the  pancreatic  juice  vary  with  the  nature  of  the  food  taken,  starchy 
food  causing  an  increase  in  the  amylase,  and  so  forth.  These  state- 
ments have  not  been  fully  confirmed  as  yet  by  other  observers.  Paw- 
low  has  also  shown  that  the  presence  of  bile  doubles  the  activity  of 
the  digestive  juices. 

Trypsin. — Trypsin  is  a  more  active  ferment  than  is  pepsin,  and 
acts  in  alkaline,  neutral,  or  even  in  slightly  acid  media.  It  is  most 
active,  however,  in  alkaline  solutions.  The  process  by  which  peptones 
are  formed  from  proteins  is  similar  to  that  of  peptic  digestion,  but 
differs  somewhat  in  detail.  Trypsin,  however,  is  capable  of  carrying 
on  the  digestion  of  peptones  further  than  is  pepsin.  The  steps  in  the 
hydrolysis  of  the  protein  molecule  by  trypsin  have  been  the  subject 
of  a  very  great  amount  of  study.  The  trypsin,  like  the  pepsin,  hydro- 
lyzes  the  simple  proteins  first  to  a  proteose,  and  then  to  a  peptone 
stage,  but  the  latter  product  may  be  split  still  further  into  a  variety 
of  simpler  bodies,  the  number  and  character  of  which  depend  on  the 
amount  of  trypsin  and  the  time  that  it  acts.  The  actual  products 
formed  depend  on  the  length  of  time  the  trypsin  is  allowed  to  act 
and  the  conditions,  favorable  or  unfavorable,  under  which  it  acts. 
The  end  products  formed  are  the  amino-acids. 

The  digestion  of  gelatinoids  is  similar  to  that  of  the  proteins. 
Trypsin  produces  gelatin-peptone,  whereas  pepsin,  as  previously 
stated,  ceases  to  act  with  the  formation  of  gelatose. 

Amylase  converts  starch,  by  hydrolysis,  into  maltose  and  achro- 
odextrin,  in  the  same  way  that  ptyalin  does.  Before  absorption  the 
substances  are  further  acted  upon  by  the  maltase  of  the  intestinal 
secretion    and    converted    to    dextrose.     It    is    important    that    the 


32  CHEMISTRY  AND  PHYSIOLOGY  OF  DIGESTION 

starches  should  be  completely  digested  in  the  small  intestines,  espe- 
cially as  a  large  part  of  the  heat  and  energy  consumed  by  the  body  is 
derived  from  some  form  of  starchy  food. 

Steapsin,  known  also  as  lipase,  splits  up  the  neutral  fats  into  glycerin 
and  free  fatty  acids.  This  emulsifieation  is  of  paramount  importance 
in  fat-digestion  and  absorption.  The  process  now  becomes  again  one 
of  hydrolysis.  The  fat  takes  up  water  and  splits  up  into  other  prod- 
ucts.    The  following  formula  explains  the  process : 

CsHs  ( C  H,  „-f  ,000 )  3  +  3H,0  =  C3H5  ( OH )  3  +  3  ( C„  U,^,+  iCOOH ) 
Fat.  Glycerin.  Free  fatty  acid. 

There  are  two  views  concerning  the  absorption  of  fat.  The  older 
view  is  that  the  fat  splits  or  is  saponified  only  to  a  small  extent,  the 
larger  part  of  it  being  emulsified  by  the  fatty  acids  formed  during 
the  splitting-up  process.  This  emulsified  fat  is  then  directly  absorbed 
as  neutral  fat.  The  view  more  recently  adopted  is  that  all  the  fat  is 
split  up  into  glycerin  and  fatty  acids,  whether  or  not  emulsifieation 
has  previously  occurred.  The  fatty  acids  are  saponified  by  the  action 
of  the  alkaline  salts  in  the  intestine,  the  products  being  then  absorbed, 
and  brought  into  combination  again  to  form  a  neutral  fat.  This  re- 
combination may  occur  in  the  epithelial  cells  of  the  intestine.  The 
action  of  lipase  is  reversible,  that  is,  it  may  split  up  the  fats  or  it 
may  cause  synthesis  of  the  split  products.  Lipase  is  found  in  many 
tissues  of  the  body,  as  liver,  muscle,  and  mammary  glands.  It  is 
possible  that  fat  is  split  and  re-formed  many  times  in  the  processes  of 
nutrition. 

Emulsifieation  takes  place  more  rapidly  in  the  presence  of  bile  and 
pancreatic  fluid  than  in  the  presence  of  pancreatic  fluid  alone.  Al- 
though bile  itself  causes  no  emulsifieation,  it  aids  very  materially  in 
the  process. 

Intestinal  Secretion. — This  is  the  secretion  of  the  intestinal  glands, 
the  crypts  of  Lieberkiihn.  It  is  strongly  alkaline  from  the  presence 
of  sodium  carbonate,  and  this  may  aid  in  the  emulsifieation  of  fat. 
Otherwise  the  intestinal  secretion  probably  has  no  action  on  the  pro- 
teins or  fats.  The  secretion  and  the  walls  of  the  small  intestines  con- 
tain three  ferments  which  act  upon  carbohydrates.  These  are  inver- 
tase,  which  acts  upon  cane-sugar;  maltase,  which  acts  upon  maltose 
and  dextrin,  and  lactase,  which  acts  upon  lactose.  The  walls  of  the 
intestines  contain  also  erepsin  and  enterokinase.  Erepsin  probably 
continues  or  supplements  the  change  begun  by  trypsin.  This  enzyme 
acts  especially  upon  the  proteoses  and  peptones,  causing  further 
hydrolysis.  The  digestion  of  the  protein  begun  by  the  pepsin  or  the 
trypsin  is  carried  to  completion  by  the  action  of  the  erepsin.  Erepsin 
has  been  found  by  Vernon  in  all  the  tissues  of  the  body.  It  is  present 
in  the  kidneys  in  greater  quantities  than  in  the  intestinal  mucosa. 
Enterokinase  acts  upon  the  pancreatic  juice.     Apart  from  the  smaU 


DIGESTION  AND  ABSORPTION  33 

intestine  the  pancreatic  juice  has  no  digestive  action  on  proteins. 
The  explanation  of  this  is  that  the  juice  contains  a  substance,  tryp- 
sinogen,  capable  of  being  converted  into  trypsin  by  the  action  of  en- 
terokinase.  As  soon  as  the  pancreatic  juice  comes  in  contact  with 
the  intestinal  wall  the  previously  inert  trypsinogen  is  changed  into 
the  very  active  ferment,  trypsin. 

Secretin. — This  is  not  an  enzyme,  but  a  definite  chemical  compound. 
It  is  secreted  by  the  wall  of  the  small  intestine  when  acids  are  brought 
in  contact  with  it.  Secretin  is  supposed  to  be  absorbed  by  the  blood, 
and  being  thus  carried  to  the  pancreas,  excites  the  secretion  of  the 
pancreatic  juice.  As  we  descend  the  intestinal  tract  the  quantity  of 
enzymes  contained  in  the  intestinal  secretion  becomes  smaller.  The 
large  intestine  secretes  mucus  but  no  enzymes. 

Bacterial  Changes. — The  changes  produced  by  bacteria  are  an  ex- 
tremely important  factor  in  digestion,  especially  from  the  pathologic 
standpoint.  The  subject  can  not,  however,  be  entered  upon  fully 
here,  and  for  a  complete  knowledge  the  student  should  consult  the 
special  text-books  on  bacteriology.  For  our  present  purpose  it  is 
sufficient  to  say  that,  in  the  small  intestine,  bacterial  changes  are 
probably  limited  to  the  carbohydrates.  Under  abnormal  conditions, 
or  when  excessive  quantities  of  protein  food  are  taken,  putrefaction 
of  the  proteins  may  occur.  In  the  large  intestine,  however,  the  ex- 
treme alkalinity  overcomes  this  acidity,  and  allows  putrefaction  of 
the  feces  to  take  place.  The  products  of  bacterial  action  are  many, 
and  consist  of  leucin,  tyrosin,  phenol,  skatol,  and  various  acids  and 
gases.  Some  of  these,  after  having  undergone  certain  changes,  are 
absorbed  and  excreted  again  in  the  urine.  It  is  not  definitely  known 
just  what  part  they  play  in  the  nutrition  of  the  body.  Judging  from 
the  experiments  of  Nuttall,  it  is  reasonably  certain,  however,  that 
bacterial  action  is  not  essential  to  nutrition. 

Liver. — The  liver  plays  an  important  part  in  the  nutrition  of  the 
body.  This  importance  is  due  largely  to  the  bile  which  it  secretes, 
and  which  is  an  adjuvant  to  intestinal  digestion,  and  to  the  action  of 
the  liver-cells  on  the  absorbed  food-material  as  it  is  found  in  the  portal 
circulation. 

The  bile  contains  bile-pigments,  bile  acids  (glycocholic  and  tauro- 
cholic),  cholesterin,  lecithin,  fats,  and  nucleo-albumin. 

The  function  of  the  hile-pigmeyits  is  obscure.  Evidently  they  are 
waste-products  of  metabolism.  The  Mle  acids  are  believed  to  play  an 
important  physiologic  role.  They  dissolve  the  cholesterin  and  facili- 
tate the  absorption  of  fats.  Cholesterin  is  regarded  as  a  waste-prod- 
uct formed  in  various  tissues,  and  is  excreted  by  the  liver-cells,  as  well 
as  by  the  skin  glands,  and  the  mammary  gland.  Lecithin  is  also  a 
waste-product.  Antiseptic  properties  have  been  ascribed  to  the  bile, 
a  property  that  has  never  been  demonstrated.  When  a  biliary  fistula 
occurs  and  the  bile  is  diverted  from  the  intestine,  the  feces  are  very 
3 


34  CHEMISTRY  AND  PHYSIOLOGY  OP  DIGESTIOX 

light  ill  color  and  give  off  a  fetid  odor,  especially  if  large  quantities 
of  meat  and  fat  are  taken.  The  antiputrefactive  action  of  the  bile  is 
probably  an  indirect  one.  In  those  patients  in  whom  the  supply  of 
bile  is  cut  oft'  from  the  intestine  a  considerable  amount  of  undigested 
and  unabsorbed  food  passes  through  the  intestine.  It  has  been 
proved,  however,  that  in  healthy  animals  the  entire  supply  of  bile  may 
be  diverted  and  the  animals  still  continue  healthy,  which  shows  that 
the  functions  of  the  bile  can,  to  a  certain  extent,  be  replaced.  The 
bile  also  helps  to  arrest  peptic  digestion  in  the  intestine. 

PECULIARITIES  OF  THE  DIGESTION  IN  INFANTS 

Salivary  Glands. — The  reaction  of  the  new-born  baby  is  neutral  or 
faintly  alkaline,  but  in  older  babies  the  reaction  is  acid,  evidently 
due  to  the  decomposition  of  the  food  remaining  in  the  mouth.  Saliva 
is  secreted  early  in  the  first  week  and  is  active,  but  is  probably  not 
a  very  important  feature  of  digestion.  After  six  months  of  age  the 
addition  of  starchy  foods  increases  the  activity  and  quantity  of  the 
saliva. 

The  Stomach. — In  the  fetus  the  stomach  is  vertical,  but  by  birth 
it  is  nearly  transverse.  It  has  no  definite  size  or  shape,  but  this 
varies  as  shown  by  Roentgen  ray  examinations:  with  its  contents,  the 
amount  of  gas  present  and  the  position  of  the  child.  The  size  of  the 
stomach  is  apparently  very  variable.  Holt  gives  the  following  table 
of  the  capacity  of  the  stomach  as  deiermined  hy  post-mortem. 

Age.                                                                 Number  of  eases.   Average  capacity. 

Birth 5  1.20  ounces 

2  weeks 7  1.50  " 

4       '•        4  2.00  " 

6       "       11  2.27  " 

8       "       4  3.37  " 

10       " 2  4.25  " 

12       "        6  4..50 

14-18    weeks    12  5.00  " 

5-6   months    14  5.75  " 

7-8           "       9  6.88 

10-11        "        7  8.14  " 

12-14       "        10  8.90  " 

As  soon  as  the  child  begins  to  take  food  the  stomach  begins  to 
empty  itself  so  that  some  of  it  passes  into  the  intestines,  enabling  the 
baby  to  take  more  food  at  a  feeding  than  would  be  indicated  by  the 
stomach  measurements.  The  length  of  time  the  food  remains  in  the 
stomach  varies  greatly.  This  subject  has  been  studied  by  test  meals 
and  the  Eoentgen  ray.  The  breast  fed  baby  probably  empties  the 
stomach  in  from  one  and  a  half  to  two  hours,  and  a  little  longer  for 
the  older  ones.  The  size  of  the  meal  and  character  of  the  food  may 
increase  the  length  of  time  and  cow's  milk  may  remain  in  the  stomach 
three  hours  or  more.  In  mixed  feeding  the  carbohydrates,  not  re- 
quiring stomach  digestion,  pass  out  first,  the  proteins  next  and  the 


PECULIARITIES  OF  THE  DKiEISTIOX  IN  INFANTS  35 

fats  last  of  all.  If  a  second  feeding  is  given  before  the  stomach  is 
empty  the  first  meal  is  hurried  along.  The  more  dilute  and  fluid  the 
food  the  more  rapidly  the  stomach  is  emptied. 

The  cardiac  end  of  the  stomach  seems  to  be  used  largely  to  hold  the 
food  and  from  there  it  is  passed  to  the  pyloric  end,  where  it  is  more 
actively  mixed.  The  pyloric  valve  opens  and  shuts  from  time  to  time 
allowing  the  food  to  pass  and  this  seems  to  depend  largely  on  the  re- 
action on  the  duodenal  side,  an  acid  reaction  closing  the  valve,  an 
alkaline  one  allowing  it  to  open.  When  the  food  is  made  acid  or 
alkaline  it  remains  longer  in  the  stomach. 

The  Secretions. — Pepsin  is  present  in  the  stomach  at  birth  and 
later  is  more  abundant  in  the  artificially  fed  than  the  breast  fed.  It 
also  seems  to  vary  in  healthy  infants  more  according  to  the  age  than 
the  weight.  In  digestive  disturbances  it  may  be  absent.  Eennin 
plays  an  important  part  in  infant  digestion  and  it  coagulates  mother's 
milk  in  loose  flakes,  whereas  cow's  milk  is  coagulated  in  large  curds. 
This  fact  should  be  borne  in  mind  in  feeding  cow's  milk  to  young  in- 
fants, and  the  milk  should  be  so  modified  as  to  prevent  curdling  in 
large  masses.  The  reaction  of  the  stomach  is  acid,  due  to  the  presence 
of  hydrochloric  acid  and  in  children  fed  on  cow's  milk  lactic  acid  may 
be  demonstrated.  This  is  formed  by  the  action  of  bacteria  or  secre- 
tions in  the  food.  The  action  of  alkalis  on  the  acid  of  the  stomach  is 
not  perfectly  clear  and  there  are  conflicting  opinions  on  this  point. 
Fat  splitting  ferments,  lipase,  is  found  at  an  early  age  and  increases 
as  the  baby  gets  older. 

Absorptions  of  glucose  solutions  and  proteins  may  occur,  but  water 
is  not  absorbed  from  the  stomach.  Various  drugs,  such  as  iodine,  may 
be  absorbed  directly. 

Intestinal  digestion  depends  on  certain  ferments,  erepsin,  which 
acts  on  the  proteins,  invertin,  lactose,  and  maltose.  The  bile  splits  fat 
and  activates  the  pancreas.  The  pancreas  secretion  contains  three 
ferments,  trypsin,  that  splits  protein,  steapsin,  which  splits  neutral 
fats  into  glycerine  and  fatty  acids,  and  amylopsin,  which  acts  on 
starch  converting  it  to  sugar.  The  pancreatic  digestion  is  not  as 
active  as  later,  but  trj^psin  and  steapsin  have  been  demonstrated  at 
birth  or  near  it.  The  intestine  produces  secretion  which  has  been 
found  at  birth.  This  acts  through  the  circulation  activating  the  pan- 
creas.    Enterokinase  has  also  been  demonstrated  in  the  newly  born. 

Tobacco  and  Digestion. — Tobacco  frequently  plays  an  important 
role  in  influencing  the  digestion  of  food.  It  is  a  well-known  fact  that 
the  chewing  of  tobacco  increases  the  salivary  secretion,  frequently  re- 
duces the  appetite,  and  increases  the  movements  of  the  bowels.  As  a 
rule,  it  is  better  to  smoke  after  meals  than  before,  the  irritating  efi^ect 
of  tobacco  being  thus  lessened.  In  acute  gastric  disturbances  tobacco 
should  be  interdicted  entirely,  and  in  chronic  forms  the  smoking 
should  be  limited  to  a  very  few  cigars  a  day. 


36  CHEMISTRY  AND  PHYSIOLOGY  OF  DIGESTION 

Tobacco  acts  as  an  excitant  to  the  nervous  system,  and  should  be 
prohibited  in  all  nervous  diseases. 

ABSORPTION 

In  order  properly  to  understand  digestion  and  assimilation  it  is 
necessary  to  know  something  of  absorption.  This  occurs  in  two  ways : 
either  by  the  material  absorbed  entering  directly  into  the  blood  and 
passing  thence  to  the  liver,  or  by  its  entering  the  lacteals  and  passing 
thence  through  the  thoracic  duct  to  enter  the  blood  current  of  the  left 
jugular  and  subclavian  veins. 

Absorption  was  formerly  believed  to  take  place  to  a  very  marked 
extent  in  the  stomach.  This  view  is  now  held  to  be  erroneous,  prob- 
ably little  or  no  absorption  taking  place  in  this  organ.  Water,  as  well 
as  most  other  liquids,  may  be  absorbed  slightly  from  the  stomach. 
Alcohol  may  be  absorbed  in  it,  and  solutions  of  various  salts  may  be 
absorbed  slowly.  Condiments,  by  stimulating  the  mucous  membrane  of 
the  stomach,  and  increasing  the  secretion  of  gastric  juice,  aid  in 
stomach  absorption.  Fats  are  not  absorbed  by  the  stomach.  Pro- 
teins and  sugars,  if  taken  in  sufficiently  concentrated  solutions,  may 
be  absorbed,  the  congestion  brought  about  by  the  use  of  alcohol  or 
condiments  aiding  the  absorption.  On  the  whole,  however,  absorption 
from  the  stomach  is  of  trifling  importance. 

Absorption  in  the  Intestine. — Absorption  takes  place  principally 
in  the  small  intestine.  Food  passes  from  the  small  intestine  in  from 
five  to  twenty  hours.  On  entering  the  large  intestine  the  food  is  still 
in  a  very  fluid  condition,  notwithstanding  the  large  amount  of  ab- 
sorption of  water  and  salts  that  takes  place  during  its  passage  through 
the  small  intestine. 

The  absorption  of  water  is  a  special  function  of  the  intestinal 
epithelium,  and  not  a  simple  question  of  osmosis.  Solutions  that 
closely  resemble  the  blood  as  regards  alkalinity  may  rapidly  be  ab- 
sorbed. The  water  absorbed  is  taken  up  directly  by  the  capillaries, 
without  first  passing  through  the  lacteals,  although  if  very  large 
quantities  are  taken,  this  last  may  occur.  Our  knowledge  of  intestinal 
absorption  is  due  largely  to  the  experiments  of  Heidenhain. 

The  absorption  of  water  is  largely  replaced  by  the  abundant  secre- 
tion of  the  small  intestine. 

The  protein  food  is  absorbed  as  amino-acids  which  enter  the  blood 
stream  and  circulate  in  it  as  such  to  be  utilized  in  building  up  and  re- 
pairing the  tissues.  The  excesses  are  deaminized  in  the  liver.  (See 
Amino-acids.) 

The  carbohydrates  are  absorbed  as  dextrose  or  as  levulose.  Dex- 
trose can  be  demonstrated  in  the  blood,  and  if  solutions  of  this  sub- 
stance are  injected  directly  into  the  circulation,  it  may  be  utilized  by 
the  tissues.  The  absorption  of  dextrose  from  the  intestine  is  probably 
more  than  a  simple  process  of  difi:usion  through  an  animal  membrane, 


PECULIARITIES  OF  THE  DIGESTION  IN  INFANTS 


37 


and  it  is  possible  that  a  special  activity  of  the  intestine  is  here  brought 
into  play. 

The  fats  are  absorbed  either  directly  as  such  or  in  the  form  of  fatty 
acids  and  soaps.  The  absorption  of  the  small  droplets  of  fat  directly 
is  thought  to  be  a  purely  mechanical  process.  The  fatty  acids  are 
changed  into  neutral  fats,  a  process  that  probably  takes  place  in  the 
epithelial  cells  of  the  intestine.  The  fats  pass  for  the  most  part 
directly  into  the  lacteals  and  into  the  blood  by  way  of  the  thoracic 
duct. 

Absorption  takes  place  in  the  large  intestine,  but  it  is  chiefly  an 
absorption  of  water.  The  feces  enter  in  a  very  liquid  condition,  and, 
after  making  slow  progress  for  almost  twelve  hours,  they  reach  the 
rectum  in  an  almost  solid  condition.  The  large  intestine  possesses  re- 
markable powers  of  absorption,  since  peptonized  milk,  and  the  like, 
given  in  the  form  of  nutrient  enemata  or  experimentally,  may  be  ab- 
sorbed into  the  system. 

In  determining  the  degree  of  absorbability  of  food,  the  amount  of 
the  elementary  food  principles  ingested  must  first  be  ascertained,  and 
the  proportion  that  has  not  been  absorbed  determined  from  the  feces. 
The  degree  of  absorbability  of  a  food  indicates,  in  a  measure,  its  nu- 
tritive value.  According  to  Atwater,^  from  an  ordinary  mixed  meal 
an  average  of  92  per  cent,  of  protein,  95  per  cent,  of  fats,  and  97  per 
cent,  of  carbohydrates  is  absorbed  in  the  body.  "The  proportion  of 
the  several  nutrients  which  the  body  retains  for  its  use  are  commonly 
called  percentages  or  coefficients  of  digestibility."  The  following 
table,  taken  from  Atwater,  gives  these  coefficients  of  digestibility : 


Coefficients  of  Digestibility  and  Fuel-value  per  Pound  of  Nutrients  in 
Different  Groups  of  Food-materials. 


Kind  of  food. 


Meats  and  fish  .... 

Eggs 

Dairy  products  .... 
Animal  food  (of  mixed 

diet)    

Cereals 

Legumes  (dried)  .    .    . 

Sugai-s 

Starches 

Vegetables 

Fruits 

Vegetable      foods    ( of 

mixed  diet) 
Total   food  (of   mixed 

diet)    


Protein. 


Digesti- 
bility. 


Per  cent. 
97 
97 
97 

97 

85 
78 


83 
85 

84 

92 


Fuel- 
value  per 
pound. 


Calories'. 
1940 
1980 
1940 

1940 
1750 
1570 


1410 
1520 

1840 

1820 


Fat. 


Digesti- 
biUty. 


Per  cent. 
95 
95 
95 

95 
90 
90 


90 
90 

90 

95 


Fuel- 
value  per 
pound. 


Calories. 
4040 
4090 
3990 

4050 
3800 
3800 


3800 
3890 

3800 

4050 


Carbohydrates. 


Digesti- 
bility. 


Per  cent. 
98 

98 
98 

98 
98 
97 
98 
98 
95 
90 

97 

97 


Fuel- 

\alue  per 

pound. 


Calories. 
1730 
1730 
1730 

1730 
1860 
1840 
1750 
1860 
1800 
1630 

1820 

1820 


'  Pnnciples  of  Nutrition  and  Nutritive  Value  of  Food,  Farmere'  Bulletin  No. 
142,  United  States  Department  of  Agriculture. 


38 


CHEMIiiTRY  AXD  PHYSIOLOGY  OF  DIGESTION 


Riibner  ^   gives  the  following  table,  showing  the  absorbability  of 
various  foods : 


Weight  of  same 
in  grams. 

Absorbed  in  percentage  of 

Fresh. 

Dried. 

Dried 
substance. 

Albumin. 

Fat. 

Carbo- 
hydrates. 

Ash. 

Meat 

884 

376 

95 

97 

95 

82 

Eggs 

984 

247 

.    95 

97 

95 

. 

82 

Milk 

2470 

315 

92 

94-99 

95-97 

100 

51 

Milk  and  cheese 

2490 

420 

94 

96 

97 

100 

74 

White  bread .    - 

860 

753 

95 

81 

99 

93 

Black  bread  .    . 

1360 

765 

85 

68 

89 

64 

Macaroni  .    .    . 

695 

626 

96 

83 

94 

99 

76 

Indian  com  .    . 

750 

646 

93 

85 

83 

97 

70 

Com  and  cheese 

780 

96 

93 

91 

96 

81 

Rice 

638 

552 

96 

80 

93 

99 

85 

Peas 

600 

521 

91 

83 

93 

96 

68 

Potatoes     .    .    . 

3078 

819 

91 

68 

96 

92 

84 

Cabbage     .    •    . 

3830 

406 

85 

82 

94 

85 

81 

Carrots  .... 

2566 

352 

79 

61 

94 

82 

76 

The  Absorption  of  Protein. — It  has  been  estimated  that  about  80 
per  cent,  of  the  protein  is  absorbed  in  the  small  intestine  and  14  per 
cent,  in  the  large  intestine.  The  proteins  of  animal  food  are  much 
more  completely  absorbed  than  those  in  vegetable  foods.  Meat,  for 
example,  is  very  completely  absorbed,  about  97  per  cent.,  and  there 
is  very  little  residue  left  in  the  bowel.  The  same  is  true  of  fish  and 
eggs,  which  are  absorbed  up  to  about  95  per  cent. 

Milk  is  absorbed  better  in  children  than  in  adults,  there  being 
about  4  per  cent,  residue  in  the  former  to  10  per  cent,  in  the  latter. 
When  milk  is  mixed  with  other  foods  it  is  much  more  completely 
absorbed,  in  fact,  almost  entirely. 

The  reason  why  vegetable  proteins  are  not  completely  absorbed  is 
not  clear,  but  the  fact  remains  that  the  percentage  of  residue  is  very 
high.  In  potatoes,  32  per  cent,  is  left,  while  in  carrots,  beans,  and 
lentils  about  40  per  cent,  is  left. 

Absorption  of  Fats. — These  are  very  completely  absorbed  if  not 
given  in  excessive  quantities.  Fat  contained  in  vegetable  foods  seems 
to  be  entirely  absorbed.  The  lower  the  melting-point  the  greater  the 
amount  of  absorption.  Hutchison  has  placed  the  limit  of  the  capa- 
bilities of  absorption  of  fat  of  the  ordinary  individual  at  150  grams  a 
day,  but  there  are  wide  individual  peculiarities.  Some  persons  cannot 
utilize  much  fat,  and  it  causes  diarrhea  or  other  intestinal  disturbances 
if  given  in  excessive  quantities.  The  excess  is  passed  in  the  feces. 
The  Esquimaux  can  utilize  large  quantities  of  fat,  while  in  the  tropics 
but  little  is  taken. 

Absorption  of  Carbohydrates. — Carbohydrates  are  absorbed  more 

^  Zeitschr.  f.  Biol.,  vol.  xv.,  p.   115. 


PECULIARITIES  OF  THE  DIGESTION  IX  INFANTS  39 

completely  thau  either  fats  or  protein.  Sugar  is  completely  absorbed, 
and  starch  too  unless  given  in  certain  forms.  Under  ordinary  circum- 
stances they  leave  little  or  no  residue  in  the  intestine. 

The  Absorption  of  Vegetable  Foods. — These  leave  more  or  less 
residue,  according  to  the  amount  of  cellulose  and  fiber  they  contain. 
Some  cereals,  as  rice,  are  nearly  completely  absorbed,  only  about  19 
per  cent,  of  the  protein  being  left.  Oatmeal,  on  the  other  hand, 
leaves  considerable  residue.  The  legumes  as  ordinarily  given  leave  a 
considerable  residue,  but  if  given  in  finely  divided  forms,  as  in  legume 
flours,  they  are  fairly  well  absorbed.  Koots  and  tubers  leave  a  con- 
siderable residue,  according  to  the  amount  of  cellulose  contained. 
Potatoes  are  absorbed  very  completely. 

Green  vegetables  and  fruits  leave  considerable  residue.  Some  green 
vegetables,  as  cabbage,  contain  but  little  nutriment. 

Digestibility  of  Vegetable  Fats. — Langworthy  and  Holmes  have 
studied  the  digestibility  of  some  of  the  vegetable  fats  and  find  that  with 
allowance  for  metabolic  products,  the  coefficients  of  digestibility  have 
been  found  to  be  for  olive  oil  97.8 ;  for  cottonseed  oil  97.8 ;  for  peanut 
oil  98.3 ;  for  cocoanut  oil  97.9 ;  for  sesame  oil  98 ;  for  cocoa  butter  94.9. 
These  figures  show  that  with  the  exception  of  cocoa  butter  all  these 
oils  have  essentially  the  same  coefficient  of  digestibility  and  about 
equal  the  animal  fats  in  this  respect.  The  melting  point  of  these 
fats  is  considerably  below  that  of  the  human  body  and  with  the 
exception  of  cocoa  butter  they  are  very  well  utilized  by  the  body. 
The  digestibility  of  the  protein  and  carbohydrate  contained  in  the 
different  fat  diets  was  not  materially  affected  by  the  amount  or  nature 
of  the  fat. 

Absorption  in  Mixed  Diet. — This  is  better  than  when  the  various 
kinds  of  foods  are  given  alone.  Atwater  has  shown  that  the  following 
proportions  of  the  alimentary  principles  are  absorbed  when  the  indi- 
vidual takes  a  mixed  diet : 

Protein. 

Animal  foods   98  per  cent. 

Cereals  and  sugars 85 

Vegetables  and  fruits    .  .   80       '" 

Practical  Value  of  Absorbability  in  Diets. — On  an  ordinary  mixed 
diet  there  is  sufficient  residue  to  form  normal  feces.  When  there  is 
diarrhea  or  intestinal  disturbances  the  foods  chosen  should  be  those 
which  are  as  completely  absorbed  as  possible.  On  the  other  hand, 
when  there  is  constipation,  foods  having  a  considerable  residue  are 
valuable,  so  that  fruits  and  green  vegetables  and  the  roots  and  tubers 
containing  a  considerable  amount  of  cellulose  and  fiber  should  be 
chosen. 


Fats. 

Carbohydrates. 

97  per  cent. 

100  per  cent. 

96       •• 

98       " 

90       '• 

95       " 

40  CHEMISTRY  AND  PHYSIOLOGY  OF  DIGESTION 


THE  INFLUENCE  OF  VARIOUS  FACTORS  UPON  THE 

DIGESTION 

The  digestibility  of  a  food  is  important.  No  matter  what  its  vame 
in  calories  or  its  protein  or  other  content,  if  the  individual  who  eats 
it  cannot  digest  the  meal,  it  is  of  little  value.  In  dealing  with  the  sick 
this  is  of  especial  importance.  In  arranging  a  diet  this  must  always 
be  taken  into  consideration. 

Apart  from  the  selection  of  a  proper  diet,  important  factors  that 
especially  affect  the  digestion  are  the  following:  1.  The  hours, 
order  and  frequency  of  meals.  2.  Variety  in  diet.  3.  The  appe- 
tite. 4.  The  temperature  of  food.  5.  Rest  and  exercise  before 
and  after  meals.     6.     Emotion. 

I.  Order  and  Frequency  of  Meals. — It  is  usually  customary  to 
fix  certain  hours  for  the  taking  of  meals ;  these  hours  vary  with  the 
occupation  of  the  individual.  In  large  cities,  where  the  noon  hour  is 
taken  up  largely  with  active  business  pursuits,  evening  is  selected 
as  the  most  convenient  hour  for  dinner.  Sir  Henry  Thompson  states 
that  three  general  systems  are  in  use  according  to  which  two,  three  or 
four  meals  are  taken  daily.  The  first  system,  which  consists  of  two 
meals  a  day,  is  followed  in  France  and  other  countries  on  the  continent 
of  Europe.  A  substantial  meal,  consisting  of  fish  or  meat  and  other 
courses  of  solid  foods,  is  eaten  about  noon ;  no  food  is  taken  before  the 
noon  meal,  except  on  arising,  when  a  cup  of  coffee  or  chocolate  and  a 
small  quantity  of  bread  and  butter  are  taken.  The  second  meal, 
which  is  dinner,  is  eaten  between  6  and  7  o'clock  in  the  evening. 
This  meal  is  the  largest  meal  of  the  day,  and  consists  of  soup,  fish, 
meat,  vegetables,  salads,  dessert,  and  black  coffee.  The  second  sys- 
tem, commonly  in  vogue  in  England,  consists  of  four  meals  daily. 
The  first  meal,  or  breakfast,  is  taken  at  about  8  a.  m.,  and  consists  of 
cocoa,  tea,  or  coffee,  bread,  butter,  bacon,  fish,  or  eggs ;  dinner  is  eaten 
between  1  and  2,  and  consists  of  soup,  meat,  fish,  vegetables,  and  pud- 
ding ;  tea  is  taken  at  5  p.  m.,  and  supper  is  served  at  8,  and  consists  of 
meat,  fish,  vegetables,  and  stewed  fruits.  Dinner  is  taken  in  the 
evening  by  the  well-to-do  classes,  and  a  substantial  lunch  is  usually 
taken  at  noon.  The  third  system,  practised  in  the  United  States, 
consists  in  taking  three  meals  daily.  In  many  towns  it  is  customary 
to  dine  at  noon ;  in  others,  in  the  evening.  The  usual  breakfast,  taken 
between  7  and  8  a.  m.,  consists  of  fruits,  breakfast  food  or  cereals, 
eggs,  bacon,  or  salt  fish,  tea,  cocoa  or  coffee,  and  bread  and  butter. 
Luncheon,  eaten  between  12.30  and  2  o'clock,  consists  of  cold  meat  or 
a  chop,  vegetables,  salads,  and  dessert.  Dinner,  eaten  between  6.30 
and  8  p.  m.,  is  the  heaviest  meal  of  the  day,  and  consists  of  soup,  fish, 
meats,  vegetables,  salads,  and  fruit. 

The  conventional  order  of  taking  food  at  dinner  appears  to  be  most 
rational,  namely,  soup,  fish,  entree,  meat,  vegetables,  salads,  fruits. 


INFLUENCE  OF  VARIOUS  FACT0R8  UPON  DIGESTION  41 

Small  quantities  of  soup  stimulate  the  gastric  secretion,  do  not  inter- 
fere with  digestion,  and  pass  rapidly  from  the  stomach ;  the  tish  and 
entree  are  then  partaken  of,  before  the  acidity  of  the  gastric  secretion 
has  reached  its  height ;  next  follows  the  meat,  the  stomach  now  secret- 
ing liberal  quantities  of  gastric  juice  wherewith  to  carry  on  the  diges- 
tive processes ;  finally  come  the  carbohydrates,  which  do  not  undergo 
digestion  in  the  stomach,  and  which  enter  this  organ  when  the  food 
already  taken  is  about  to  pass  from  the  stomach  into  the  intestine. 
The  eating  of  bountiful  dinners,  made  up  of  many  courses,  when  fre- 
quently indulged  in,  is  likely  to  lead  to  digestive  disturbances.  Chil- 
dren and  invalids  should  always  eat  dinner  at  midday,  between  12  and 
2  o'clock,  and  should  never  be  allowed  to  take  this  meal  at  night. 

The  frequency  of  meals  must  be  regulated  according  to  individual 
conditions.  Patients  suffering  from  digestive  disturbances  and  those 
who  take  very  small  quantities  of  food  at  a  time  require  nourishment 
at  frequent  and  regular  intervals;  whereas  those  whose  digestion  is 
feeble,  should  allow  six  or  seven  hours  to  elapse  between  meals ;  or- 
dinarily the  interval  between  meals  should  be  about  four  or  five  hours, 
this  being  about  the  time  necessary  for  complete  digestion  of  a  mixed 
meal  in  the  stomach.  The  habit  of  habitually  omitting  the  noon 
luncheon,  so  commonly  practised  by  busy  Americans,  should  be  dis- 
couraged. 

2.  Variety  in  Diet. — In  order  thoroughly  to  satisfy  the  needs  of 
the  body  the  diet  must  be  varied.  Although  a  diet  restricted  to  but  a 
few  articles  of  food  may  contain  a  sufficient  quantity  of  the  alimentary 
principles  to  sustain  the  body  nutrition,  yet  the  monotony  of  such  a 
diet  becomes  so  objectionable  that  it  can  not  be  digested  thoroughly. 
According  to  Woods  and  ]\Ierrill,^  "  it  is  a  matter  of  common  observa- 
tion that  digestion  experiments  made  with  one  kind  of  food-material 
do  not  give  on  the  whole  as  reliable  results  as  those  in  which  two  or 
more  food-materials  are  used.  In  other  words,  it  appears  that  with  a 
mixed  diet  the  same  person  will  digest  a  larger  proportion  of  nutrients 
than  with  a  diet  composed  of  a  single  food-material.''  Certain  races 
restrict  the  variety  of  food  from  religious  motives,  such  as  the  Jewish 
restriction  of  ham,  pork,  and  oysters.     (See  Leviticus,  chapter  xi.) 

3.  Appetite. — Appetite  is  the  desire  for  food,  and  is  dependent 
upon  various  conditions.  It  is  controlled  by  the  sensation  of  hunger, 
and  is  often  induced  by  the  sight,  smell  and  taste  of  food.  As  Pawlow 
has  shown,^  the  smell  or  sight  of  food  will  excite  the  flow  of  the  gastric 
secretion,  and  this  in  turn  will  produce  an  appetite.  Simple  bitters 
or  some  form  of  alcoholic  drink  will  at  times  induce  this  sensation. 
The  appearance  of  badly  prepared  or  improperly  served  food  will 
often  dispel  the  appetite.  In  children  the  appetite  is  usually  good, 
whereas  in  the  aged  it  is  lessened.     Some  persons  have  voracious  appe- 

1  United  States  Department  of  Agriculture  Bulletin  No.  85. 

2  The  Work  of  the  Digestive  Glands. 


42  CHEMISTRY  AXD  PHYSIOLOGY  OF  DIGESTION 

tites,  and  abnormal  craving  for  food.  This  is  often  the  case  in 
diabetic  and  other  conditions,  when,  at  times,  the  appetite  can  not  be 
satisfied. 

4.  Temperature  of  Food. — The  temperature  of  food  when  taken 
is  of  considerable  importance.  The  ideal  temperature  is  that  of  the 
body,  from  98°  to  100°  F.  (Uffelmann),  the  limits  of  safety  being 
between  45°  and  130°  F.  According  to  Hutchison,  extremes  of  tem- 
perature of  food  are  apt  to  give  rise  to  gastric  disturbances,  such  as 
gastric  catarrh.  Uftelmann  states  that  a  drink  at  a  temperature  of 
122°  F.  increases  the  body-temperature  0.1  to  0.3  degree  C.  It  is 
believed  by  many  that  ulcer  of  the  stomach,  so  common  in  cooks,  is 
often  due  to  the  taking  of  too  hot  foods.  Hutchison  considers  that 
the  proper  temperature  of  water  intended  to  quench  the  thirst  should 
be  between  50°  and  70°  F. 

5.  Rest  and  Exercise  before  and  after  Meals. — It  is  often  ad- 
visable to  rest,  but  not  to  sleep,  after  meals.  The  larger  part  of  the 
work  of  the  stomach  should  be  completed  before  retiring  at  night, 
otherwise  the  sleep  is  apt  to  be  disturbed.  About  one  or  two  hours 
should  be  allowed  to  elapse  between  a  light  evening  meal  and  bedtime, 
and  three  or  four  hours  between  a  heavy  meal  and  sleep.  From  per- 
sonal observations  (see  the  section  on  Rest  and  Sleep  in  Gastric  Dis- 
turbances) the  authors  have  concluded  that  digestion  is  improved  by 
rest  after  meals,  but  impaired  by  sleep.  In  many  instances  a  period 
of  rest  before  eating  meals  is  a  valuable  aid  to  digestion.  Violent  ex- 
ercise immediatel}^  after  meals  inhibits  digestion,  whereas  moderate 
exercise  one  or  two  hours  after  meals  materially  aids  this  process. 

6.  Food  and  Emotion. — Severe  mental  strain  and  strong  emotion 
disturb  the  digestion,  and  for  this  reason  food  should  not  be  taken 
until  a  period  of  rest  and  composure  has  intervened.  On  the  other 
hand,  pleasurable  sensations  aid  the  digestion,  and  pleasant  conversa- 
tion at  the  table  is  therefore  to  be  recommended. 

METABOLISM 

Food  is  required  for  two  purposes :  to  build  up  the  body  and  repair 
tissue-waste,  and  to  supply  energy  and  heat. 

For  purposes  of  study  food  may  be  classified  into  proteins,  fat, 
carbohydrates,  mineral  salts,  vitamins,  and  water.  These  are  more  or 
less  complex  combinations  of  the  various  elements,  oxygen,  nitrogen, 
hydrogen,  etc.  During  digestion,  assimilation,  respiration,  and  excre- 
tion the  food  taken  undergoes  many  changes,  breaking  down  into 
simpler  compounds  or  being  transformed  into  others.  These  changes 
are  termed  metahoUsm.  While  not  a  food,  the  oxygen  of  the  air  plays 
an  important  part  in  nutrition. 

In  youth,  until  the  body  attains  its  full  size,  material  is  needed  from 
which  to  build  the  tissues.  This  material  is  derived  from  the  food. 
From  birth  until  death  the  life-processes  cause  a  constant  waste  of  the 


METABOLISM 


43 


tissues,  and  this  waste  must  be  replaced  or  the  body  will  become  un- 
able properly  to  carrj-  on  its  functions.  Only  protein  substances,  that 
is  to  say,  food  containing  nitrogen,  can  be  used  for  this  purpose. 
Fat  may  be  used  to  store  material  in  the  connective  tissue  for  future 
use  as  fuel,  and  also  to  protect  the  body  from  cold. 

Every  act  consumes  energy.  If  a  man  lifts  a  pound  a  foot  high,  he 
must  reproduce  in  his  body  that  amount  of  energy.  This  energy  is 
obtained  from  the  food.  The  force  that  holds  the  food  elements  to- 
gether in  combination  is  called  potential  energy.  In  breaking  up  the 
food  into  simpler  compounds  the  body  sets  this  energy  free  or  changes 
it  into  kinetic  energy.  The  changes  by  which  this  is  brought  about 
are  not  very  well  understood  at  present,  but  they  may  be  likened  to 
combustion;  thus  we  speak  of  ''burning"  up  the  food-material  in 
the  body,  as  if  the  body  were  a  very  superior  kind  of  furnace,  for  the 
changes  that  go  on  are,  for  the  most  part,  very  probably  a  sort  of  com- 
plex oxidation.  Proteins,  fats,  and  carbohydrates  may  all  be  burnt 
up  to  furnish  heat  and  energy;  the  last  two — fats  and  carbohydrates 
- — are  used  exclusively  for  one  or  the  other  purpose,  if  we  regard  the 
fat  stored  in  the  body  merely  as  fuel  for  future  use. 

The  salts  aid  in  the  digestive  and  other  processes,  and  are  utilized  in 
the  composition  of  the  bones  and  teeth.  Water  is  probably  not  used 
to  furnish  energy,  but  it  serves  as  a  menstruum,  if  the  term  be  allow- 
able, for  the  processes.  Vitamins  are  substances  essential  to  life — at 
present  not  very  well  understood. 

Atwater  gives  the  following  table  to  illustrate  the  uses  of  the  dif- 
ferent food  elements: 


Food  as 

purchased     -{ 
contains — 


Nutritive  Ingredients  of  Food. 
Water. 


Edible  portion — e.  7.,  flesli 
of  meat,  yolk  and  white 
of  egg,  wheat  iiour,  etc. 


Nutrients. 


f  Protein. 
J   Fats. 


Cai'bohyd  rates. 
Mineral  matter. 


Refuse — e.  g.,  bones,  entrails,  shells,  bran,  etc. 


Uses  of  Nutrients  in  the  Body. 
Protein — forms  tissues — e.  g.,  white  (albumin)   of  eggs,  1 

curd  (casein)  of  milk,  lean  meat,  gluten  of  wheat,  etc. 
Fats — are  stored  as  fat — e.  g.,  fat  of  meat,  butter,  olive       All   sei-ve  as  fuel 

oil,  oils  of  corn,  wheat,  etc.  to  yield  energy 

Carbohydrates — are  ti-ansformed   into  fat— e.  g.,  sugars,   }-      in  the  forms  of 

starches,  etc.  heat    and    mus- 

Mineral  matters  (ash) — share  in  forming  bone,  assist  in  cular  power. 

digestion — e.  g.,  phosphates  of  lime,  etc.,  potash,  soda, 

etc.  J 


To  the  above  vitamins  should  be  added. 

After  the  body  has  reached  its  full  development,  the  body-weight 


44  CHEMISTRY  AND  PHYSIOLOGY  OF  DIGESTION 

remains  more  or  less  constant,  and  the  food  that  has  been  used  is  ex- 
creted by  means  of  the  respiration  and  the  urine,  and,  to  a  large 
extent,  by  the  feces. 

The  well-known  law  concerning  the  conservation  of  energy  appar- 
ently applies  to  metabolism  in  animal  bodies,  and  this  has  been  prac- 
tically proved,  although  the  experiments  have  never  quite  reached  the 
ideal  owing  to  the  almost  insurmountable  difficulties  that  attend  such 
experiments.  In  other  words,  food  that  is  used  in  the  body  furnishes 
the  same  amount  of  energy  that  it  would  furnish  if  burnt  in  a  furnace 
or  calorimeter,  providing  the  end-products  in  each  case  are  the  same. 
The  heat-values  of  foods  may  therefore  be  taken  as  a  standard  of  their 
food-value,  but  it  must  always  be  remembered  that  in  the  practical  ap- 
plication of  this  fact  in  working  out  dietaries  the  digestibility  and 
adaptability  of  a  food  are  of  great  importance,  as  well  as  the  amount 
of  energy  it  contains. 

The  heat-value  of  various  foods  may  be  determined  experimentally 
by  the  use  of  an  instrument  known  as  a  bomb  calorimeter,  the  result 
being  expressed  in  calories.  A  calorie  is  the  amount  of  heat  that  is 
necessary  to  raise  the  temperature  of  1  kilogram  of  water  1  degree  C. 
(It  is  nearly  the  same  as  the  amount  required  to  raise  1  pound  of 
water  4  degrees  F.)  This,  expressed  in  mechanical  force,  means  that 
a  calorie  would  raise  a  ton  about  1.54  feet,  or  that  it  is  equal  to  1.54 
foot-tons. 

According  to  Atwater,  the  fuel-value  of  the  various  classes  of  food 
as  ordinarily  supplied  is  as  follows: 

1  gram  of  protein  furnishes  4  calories ;  1  pound  furnishes  1820  calories. 

1  "        fat  "  8.0     •'        ;  1        "  "  4040 

1         "        carbohydrate  furnishes  4  calories;   1  pound  furnishes  1820  calories. 

These  figures  are  somewhat  lower  than  the  figures  given  by  older 
estimations,  and  are  based  upon  the  most  recent  experiments.  The 
fuel-values  formerly  given  were :  protein  and  earboh.ydrates,  4.1  cal- 
ories per  gram;  fat,  9.3  calories  per  gram.  It  will  be  observed  that 
fat  has  a  very  high  food-value,  which  doubtless  explains  why  it  is 
stored  as  a  reserve  fuel. 

The  earlier  metabolism  studies  were  largely  concerned  with  the 
chemical  composition  of  the  food  as  taken  into  the  body  and  the 
composition  of  the  urine  and  feces.  Chemical  balance  sheets  dealing 
chiefly  with  the  carbon  were  prepared  by  Liebig  as  early  as  1840. 
The  nitrogen  balance  and  the  balances  of  calcium,  magnesium  and  the 
other  constituents  have  come  in  for  a  large  amount  of  work  and  we 
are  but  on  the  threshold.  In  addition  to  the  chemical  balances  the 
study  of  the  energy  metabolism  and  the  gaseous  exchange  have  oc- 
cupied the  time  of  the  more  recent  investigators.  The  first  respira- 
tory calorimeter  was  built  by  Pettenkofer  and  Voit.  Since  then  Rub- 
ner,  Zuntz  and  Geppert,  Pashutin  and,  in  this  country,  Atwater  and 


METABOLISM  45 

Rosa,  Benedict,  Liisk,  and  many  others  have  worked  with  this  valuable 
apparatus.  The  Atwater-Rosa  calorimeter  was  built  at  Middletowu, 
Connecticut,  but  has  been  moved  to  Washington.  Langworthy  and 
]\lilner  have  described  it  in  detail  in  the  Journal  of  Agricultural  Re- 
search, Volume  5,  No.  8,  and  a  shorter  account  will  be  found  in  Lusk's 
Science  of  Nutrition.  This  first  American  apparatus  is  a  large  affair 
capable  of  allowing  a  man  to  be  up  and  exercising  on  a  stationary 
bicycle  and  experiments  lasting  for  days  can  be  carried  on  with  it. 
The  first  work  was  largely  on  normal  individuals,  but  more  recently 
the  metabolism  of  diseased  conditions  has  been  studied.  For  this 
purpose  smaller  calorimeters  are  used,  such  as  the  Sage  apparatus 
at  Bellevue  Hospital,  which  consists  of  a  copper  box  about  the  size  of 
a  lower  berth  in  a  sleeping  car.  It  has  a  comfortable  bed,  two  win- 
dows, a  telephone,  a  fan,  a  shelf  and  a  Bowles  stethoscope  for  counting 
the  pulse.  The  patient  must  keep  quiet  and  as  this  is  difficult  for 
more  than  three  or  four  hours  the  periods  of  observation  are  limited. 
By  this  apparatus  the  amount  of  heat  produced  by  the  individual 
may  be  measured  directly  and  also  indirectly  by  calculating  the  chem- 
ical measurements  of  the  gaseous  exchange  in  terms  of  heat,  or  indirect 
calorimetry.  In  the  first  method  the  heat  given  off  is  measured 
by  its  being  taken  up  by  a  stream  of  cold  water  flowing  in  pipes  in  the 
top  of  the  box  and  the  amount  excreted  in  the  moisture  from  the  lungs 
is  calculated  from  the  amount  of  water  excreted  in  the  lungs,  which 
is  caught  up  by  a  sulphuric  acid  bottle  in  the  ventilating  current. 
The  second  method  consists  of  measuring  the  water  and  carbon  dioxid 
given  oft'.  The  water  is  collected  as  above  and  the  carbon  dioxid  by 
passing  the  air  through  weighed  bottles  of  soda-lime  and  sulphuric 
acid.  The  air  is  used  over  and  over  again  and  the  oxygen  supplied 
from  a  weighed  bomb  to  keep  the  air  normal.  The  figures  obtained 
by  dividing  the  liters  of  carbon  dioxid  produced  by  the  liters  of 
oxygen  consumed  is  the  respiratory  quotient.  Knowing  this  and  the 
amount  of  nitrogen  in  the  urine  it  is  possible  to  calculate  the  grams 
of  protein,  fat  and  carbohydrate  metabolized  each  hour,  and  by  mul- 
tiplying by  their  heat  values  the  number  of  calories. 

The  so-called  basal  metabolism  is  studied,  the  heat  produced  during 
complete  rest  fourteen  hours  or  more  after  the  last  meal,  and  this  is 
compared  to  the  normal  man.  As  Rubner  demonstrated,  the  metabol- 
ism is  proportionate  to  the  surface  area  of  the  body  and  all  animals 
have  about  the  same  heat  production  per  square  meter  of  body  sur- 
face. The  larger  animal  produces  more  heat,  but  the  amount  per  kilo 
of  body  weight  is  greater  the  smaller  the  animal,  that  is,  the  metabol- 
ism is  higher. 

The  metabolism  in  hyperthyroidism.  Graves'  disease,  is  greatly  in- 
creased, while  in  cretins  and  myxedema  it  is  greatly  decreased.  In 
typhoid  fever  the  metabolism  is  increased,  being  approximately  pro- 
portional to  the  rise  in  temperature. 


46  FOODS  AXD  THEIR  COMPOSITION 

An  account  of  the  calorimeter  in  clinical  medicine  by  DuBois,  will 
be  found  in  the  American  Journal  of  the  Medical  Sciences,  June, 
1916.      • 

The  whole  subject  is  in  its  infancy  and  the  near  future  will  doubt- 
less give  us  a  great  many  facts  of  practical  value. 

Respiration  Experiments. — As  foods  are  oxidized  in  the  body,  the 
metabolism  may  be  determined  by  estimating  the  amount  of  oxygen 
used.  The  respiration  apparatus  used  in  experiments  of  this  kind 
consists  of  a  mouth-  and  nose-piece  connected  with  apparatus  devised 
to  measure  the  inspired  and  expired  air.  The  amount  of  oxygen  en- 
tering the  lungs  and  the  amount  leaving  can  thus  be  determined,  and 
the  difference  represents  that  used  in  the  body.  This  method  has 
the  advantage  that  the  results  may  be  obtained  quickly  and  the 
apparatus  is  portable.  Estimations  are  made  from  time  to  time, 
and  the  totals  for  the  twenty-four-hour  or  other  periods  based  on 
these. 

Approximately,  1000  c.c.  oxygen  will  unite  with  either  1.05  gram 
protein,  0.5  gram  fat,  or  1.34  gram  sugar.  The  carbon  dioxid  given 
oft'  is  also  estimated,  and  this,  divided  by  the  oxygen  consumed,  gives 
the  "  respiratory  quotient."  This  is  used  in  estimating  the  total 
energy  used.  To  do  this  the  amount  of  food  used  must  be  known, 
and  this  is  determined  by  estimating  the  food  eaten  and  the  composi- 
tion of  the  urine  and  feces  as  regards  the  carbon  and  nitrogen  con- 
tained. 

FOODS  AND  THEIR  COMPOSITION. 

Not  only  is  it  desirable  to  know  about  the  digestibility  of  foods,  but 
it  is  necessary  to  know  about  the  composition  of  foods.  The  amount 
of  protein  or,  what  amounts  to  the  same  thing,  the  amount  of  nitro- 
gen in  any  given  food  is  the  first  point  of  interest.  If  the  amount 
of  nitrogen  is  known,  the  protein  content  is  obtained  by  multiplying 
by  6.25.  The  protein  content  is  important  for  many  reasons,  and  is 
considered  under  the  heading  of  The  Quantity  of  Protein  Required. 
Some  foods  contain  nitrogen  in  the  form  of  chemical  compounds,  con- 
taining C^N^  or  the  so-called  purin  bodies.  These  are  important 
in  certain  diseases,  as  gout,  and  are  taken  up  under  the  heading  of 
Purin  Metabolism  and  Gout.  The  amount  of  nitrogenous  food  is  a 
very  great  factor  in  all  diets.  The  percentage  of  fat  is  likewise  of 
importance,  and  in  some  diseases  and  under  certain  conditions  it  is 
desirable  either  to  use  large  quantities  of  fat  or  to  avoid  fatty  foods. 
The  carbohydrate  percentage  enters  largely  in  the  feeding  of  some 
patients,  as  in  diabetes  and  the  obese. 

The  Heat  and  Energy  Value  of  Food. — As  mentioned  above,  it  is 
convenient  to  think  of  foods  as  fuel,  and  that  they  each  furnish  a 
certain  available  amount  of  heat  or  energy.     So  much  in  protein,  so 


FOOD  VALVES 


47 


COMPOSITION   OF   MILK   AND  OTHER  FOOD-MATERIALS. 
Nutritive  ingredients,  refuse,  and  fuel-oalue. 


Protein.     Fals.       Carbo-     Mii 

bjdrates.  luatters. 


Water.     Befuse. 


Protein  compounds,  e.  g.,  lean  of  meat,  white  of  egg,  casein  (curd)  of  milk,  and 
gluten  of  wheat,  make  muscle,  blood,  bone,  etc. 

Fats,  e.  g.,  fat  of  meat,  butter,  and  oil,  I  serve  as  fuel  to  yield  heat  and  muscular 
Carbohydrates,  e.  g.,  starch  and  sugar,  J  power. 


48  FOODS  AND  THEIR  COMPOSITION 

much  in  fat,  so  much  in  carbohydrate.  Some  foods  are  all  protein, 
as  the  white  of  egg ;  some  all  fat,  as  butter ;  and  some  all  carbohydrate, 
as  sugar.  Most  foods  are,  however,  combinations  of  all  these,  and 
contain,  in  addition,  certain  salts  and  water.  The  water  is  not 
metabolized,  and  need  not  be  considered  in  taking  up  the  question 
of  food  values.  The  salts  furnish  so  little  energy  that  they  too  need 
not  be  counted,  but  they  are  of  very  great  value  in  metabolism,  and 
as  our  knowledge  of  them  increases  their  importance  is  more  and 
more  emphasized.  (See  Salt  Metabolism.)  There  are  many  prob- 
lems in  connection  with  the  energy  contained  in  foods,  and  they  will 
be  considered  briefly. 

There  are  two  series  of  estimates,  one  made  chiefly  by  Rubner  and 
generally  used  in  dietetic  computations.  The  other  was  made  subse- 
quently by  Atwater,  and  his  values  are  a  little  lower  and  perhaps 
more  correct.  Owing  to  the  differences,  discrepancies  will  be  found  in 
various  tables  and  in  different  books,  and  these  depend  in  part  on  the 
use  of  different  standards  in  making  the  computations.  At  the 
present  time  the  application  of  the  food  values  to  the  diet  as  made 
by  the  general  practitioner  is  only  approximate  at  best,  so  that  these 
discrepancies  are  not  so  important  as  would  seem  at  first  sight.  The 
standards  are  as  follows : 

Calories  per  Gram. 

Protein.  Pat.  Carbohydrate. 

Rubner    4.1  9.3  4.1 

Atwater    4.0  8.9  4.0 

To  determine  the  fuel  value  of  any  food  it  is  only  necessary  to 
multiply  the  percentage  contained  in  100  parts  of  the  food  by  4.1  for 
the  protein  and  carbohydrate,  and  by  9.3  for  the  fat.  For  example, 
100  grams  of  milk  contain  3,50  per  cent,  protein,  4  per  cent,  fat,  and 
4.50  per  cent,  sugar. 

Caloric  value  of  100  grams  of  that  milk  would  be 

Protein   3.50  X  4.1  =  14.35 

Fat    4.00  X  9.3  =  37.20 

Carbohydrate    4.50  X  4.1  =  18.45 

Total  value  70.00 

Numerous  tables  will  be  found  throughout  this  book  and  extensive 
ones  at  the  end  dealing  with  the  percentage  composition  in  common 
use.  If  the  caloric  value  per  pound  is  given  and  it  is  desired  to  have 
it  in  grams,  it  may  be  remembered  that  1  pound  equals  approximately 
454  grams  (453.60). 

It  is  desirable  not  only  to  know  how  many  calories  are  in  a  given, 
quantity  of  food,  but  how  much  is  furnished  by  each  constituent,  so 
that  the  diet  may  be  prescribed  that  contains  a  high  or  low  protein 
content,  a  high  or  low  fat  content,  or  a  high  or  low  carbohydrate 
content,  as  may  suit  the  particular  case  on  hand.     The  total  food 


METABOLISM  49 

requirement  must,  however,  always  be  borne  in  mind,  and  if  one  con- 
stituent is  low,  an  increase  corresponding  to  it  must  be  made  in  one 
of  the  others. 

The  fuel  values  of  meats  are  usually  stated  too  high,  as  much  of 
the  fat  supposed  to  be  included  is  trimmed  ott'  either  by  the  butcher 
or  the  cook.  The  bulk  of  a  food  gives  but  little  idea  of  its  food  value, 
as  bulk  often  means  a  high  water  content.  An  ounce  of  fat,  for  exam- 
ple, is  equal  to  about  2  pounds  of  cabbage. 

Nutritive  Ratio. — In  order  to  give  some  idea  of  the  value  in  nitro- 
gen or  protein  to  the  other  constituents  of  the  food,  what  is  called  the 
nutritive  ratio  is  often  stated  in  speaking  of  diet  or  foods. 

This  may  be  expressed  as : 

Protein  :  Carbohydrate  +  2|  Fat  :  :  I  :  x 

Carbohydrate  +  2i  Fat 

Or,  

Protein 

In  other  words,  it  expresses  the  ratio  between  the  amount  of  digestible 
protein  and  the  amount  of  digestible  carbohydrates  plus  the  digestible 
fats.  The  fats  are  expressed  in  terms  of  carbohydrates,  and  1  gram 
of  fat  is  considered  equal  to  2^1  grams  of  carbohydrate.  For  ex- 
ample, in  Volt's  standard  dietary  there  is: 

Protein    118  grams. 

Fats 56      " 

Carbohydrates    500      " 

The  digestible  part  may  be  obtained  by  using  the  coefficients  of  diges- 
tibility, and  we  find  these  amounts : 

Digestible  protein   118  X  0.92  =  10S.56 

Digestible   fat    56  X  0.95  =    53.20 

Digestible    carbohydrates    500  X  0.97  =  485 

The  fat  in  terms  of  carbohydrates  is  52.20  X  2.25  =  119.7. 

The  total  fat  and  carbohydrate  in  terms  of  carbohydrates  is  485  +  119.7  =  604.7. 

The  nutritive  ratio  is  108.56  :  604.7  or  1  :  5.5. 

Under  ordinary  conditions  the  ratio  should  not  vary  below  5  nor 
above  7.  Of  late  the  tendency  is  to  widen  the  ratio,  that  is,  to 
increase  the  carbohydrate  factor. 

Total  Food  Requirements. — The  next  question  is  how  much  food, 
i.  e.,  how  many  calories,  are  needed  by  the  body  under  ordinary  con- 
ditions. This  may  be  expressed  in  two  ways :  first,  as  so  many 
calories  per  kilo  or  per  pound  of  body-weight,  or,  as  is  frequently 
used  for  general  discussions,  the  amount  needed  by  a  man  of  average 
weight,  say  70  kilos  or  154  pounds.  The  problem  may  be  approached 
in  two  ways :  One  method  much  used  is  to  study  the  food  actually 
consumed  by  groups  of  individuals  living  under  certain  conditions, 
and  by  making  averages  determine  what  is  taken.  Just  because  a 
great  many  people  take  a  certain  amount  of  food  is  no  reason  that  it 
4 


50  FOOD  REQUIREMENTS 

represents  the  optimum,  as  it  is  well  known  that  the  food  eaten  varies 
with  the  kind  and  amount  available.  On  the  other  hand,  it  represents 
a  practical  g'uide,  as  we  know  that  large  groups  of  people  have  lived 
on  such  an  amount  of  food  and  maintained  health  and  strength  on  it. 

Another  method  in  vogue  at  present  in  the  scientific  study  of  food 
requirements  is  to  determine  the  amount  of  heat  given  otf  by  the 
body  while  in  the  calorimeter,  as  explained  above. 

There  are  but  very  few  calorimeters  in  existence,  and  the  method 
is  expensive,  so  that  more  frequent  studies  are  made  on  the  amount  of 
oxj^gen  consumed  and  the  respiratory  quotient.  This  may  be  done 
by  a  simpler  form  of  respiratory  apparatus.  Another  valuable  method 
of  study  is  to  determine  the  balance  of  the  intake  and  output  of 
nitrogen  and  carbon. 

The  following  figures  are  those  of  Rubner  for  an  adult  weighing 
65  kilos : 

During  rest  in  bed   1800  calories  or  28  calories  per  kilo. 

In   repose    2100         "  32         " 

In  light  work    2300         "  33 

In  moderate   work    2600         "  40         " 

In  hard  work   3100         '•  48 

These  requirements  vary  owing  to  circumstances,  and  the  needs  dur- 
ing illness,  as  fever,  are  not  those  of  good  health.  Some  of  the  more 
important  factors  bearing  on  the  total  food  requirement  may  con- 
veniently be  noted  here. 

Occupation  or  the  character  of  the  work  performed  has  a  great 
deal  to  do  with  the  amount  and  character  of  food  needed.  The  table 
on  the  opposite  page  from  Atwater  should  be  studied  in  this  connection. 

Tigertedt  estimates  the  food  requirements  for  various  classes  of 
labor  as  follows : 

Shoemaker    2001-2400  calories. 

Weaver    2401-2700 

Carpenter  or  mason   2701-3200       " 

Farm  laborer   3201-4100 

Excavator   4101-5000 

Lumberman     Over  5000       " 

In  this  connection  it  is  of  interest  to  note  the  results  obtained  by 
Atwater  and  Benedict.  The  following  show  the  average  requirements 
of  a  vigorous  young  man: 

Man  sleeping  65  calories  per  hour. 

Man  sitting  at  rest 100 

Man  at  light  muscular  exercise   170       " 

Man  at  active  muscular  exercise 200       " 

!Man  at  severe  muscular  exercise 450       '' 

^lan  at  very  severe  muscular  exercise 600       "' 


METABOLISM 


51 


Food-consumption  of  Persons   in  Different  Circumstances,  and   Proposed 

Dietary  Standards. 
(Quantities  per  Man  per  Day.) 


PERSONS  WITH  ACTIVK  WORK. 

Rowing  clubs  in  New  England 
Bicyclists  in  New  York  .  .  . 
Football  teams  in  Connecticut 

and  California 

Prussian  macninist 

Swedish  mechanics 


PERSONS   WITH   ORDINARY 
WORK. 

Farmers'  families  in  eastern 
United  States 

Mechanics'  families  in  United 
States 

Laborers'  families  in  large 
cities  of  United  States  .   .   . 

Laborers'  families  in  United 
States  (more  comfortable 
circumstances) 

Russian  peasants 

Swedish  mechanics 


PROFESSIONAL   MEN. 

Lawyers,    teachers,    etc.,    in 

United  States 

College  clubs  in  United  States 

German  physicians 

Japanese  professor 


MEN    WITH    LITTLE    OR    NO    EX- 
ERCISE. 

Men  (American)  in  respira- 
tion calorimeter 

Men  (German)  in  respiration 
apparatus 


PERSONS  IN  DESTITUTE  CIKCUM- 
STANCES. 

Poor  families  in  New  York 
City 

Laborers'  families  in  Pitts- 
burg, Pa 

German  laborer's  family  .   .   . 

Italian  mechanics 


MISCELLANEOUS. 

Negro  families  in  Alabama 
and  Virginia  ...  .   . 

Italian  families  in  Chicago 

French  Canadians  in  Chicago 

Bohemian  families  in  Chi- 
cago     

Inhabitants  Java  village, 
Columbian  Exposition,  1893 

Russian  Jews  in  Chicago    .  . 

Mexican  families  in  New 
Mexico 


Actually  eaten. 


Gm. 
155 
186 

226 
139 
189 


97 
103 
101 


120 
129 
134 


104 
107 
131 
123 


112 
127 


86 
103 
118 

115 

66 
137 

94 


Gm. 

177 
186 

354 
113 
110 


130 
150 
116 


147 
33 
79 


125 

148 

95 

21 


145 
111 
158 

101 

19 
103 

71 


Gm. 
440 
651 

634 
677 
714 


467 
402 
344 


534 

589 
523 


423 
459 
327 
416 


305 
302 


407 


287 
396 


440 
391 
345 

360 

254 
418 

618 


Digestible. 


Gm. 
143 
171 

208 
128 
174 


110 
119 
123 


96 
98 
121 
113 


103 
117 


79 
95 
109 

106 

61 
126 


Gm. 
168 
177 

336 
107 
104 


124 
143 

110 


140 
31 


119 

141 

90 

19 


138 
105 
150 

96 

18 
98 

67 


Gm. 
427 
631 

615 
657 
693 


453 
390 
334 


518 

571 
507 


410 
445 
317 
403 


2% 
293 


299 
278 
384 


427 
379 
335 


246 
405 


595 


Calor- 
ies. 
3955 
5005 

6590 
4270 
4590 


3415 
3355 
2810 


3925 
3165 
3330 


3220 
3580 
2680 
2345 


2380 
2430 


395     2845 


2400 
1640 
2225 


3395 
2965 
3260 

2800 

1450 
3135 

3460 


1: 

5.6 

6 


5.3 


8.2 
7.5 
6.3 


7.6 
5.4 
5.5 


7.1 
7.8 
4.3 
4 


4.5 
4 


6.9 

6.8 
7.2 
6.6 


9.3 
6.5 
6.2 

5.3 

4.7 
5 

8.7 


52 


FOOD  REQUIREMENTS 


Food-consumvtion  of  Persons   in  Different  Circumstances  and  Proposed  Dietary 

Standards. 
(Quantities  per  Man  per  Day.) 


"=3 


Actually  eaten. 


Biffestible. 


MISCELLANEOUS  {Continued). 

Chinese  dentist  in  California 

Chinese  laundryman  in  Cali- 
fornia     

Chinese  farm  laborer  In  Cali- 
fornia     

United  States  army  ration, 
peace  

German  army  ration,  peace  . 

DIETAKY  STANDARDS. 

Man  at  hard  work  (Voit)  .   . 

Man  at  moderate  work  (Voit) 

Man  with  very  hardmuscular 
work  (Atwater) 

Man  with  hard  muscular 
work  (Atwater) 

Man  with  moderately  active 
muscular  work  (Atwater)   . 

Man  with  light  to  moderate 
muscular  work  (Atwater)   . 

Man  at  "sedentary"  or 
woman  with  moderately 
aetive  work  (Atwater)  .  .  ". 

Woman  at  light  to  moderate 
muscular  work,  or  man 
without  muscular  exercise 
(.\twater) 


Gm. 
115 

135 

144 

120 

114 

145 
118 

175 

150 

125 

112 


Gm. 
113 

76 

95 

161 
39 


100 
56 

« 

('). 
(') 

(■) 

(') 


Gm. 
289 

666 

640 

454 
480 

450 
500 

(•) 

(') 
(') 
(') 

(■) 
(') 


Gm. 
106 

124 

132 

110 
105 

133 

109 

161 
138 
115 
103 


Gm. 
107 

72 

90 

153 
37 


95 
53 

(') 

(') 

(') 

(') 

(■) 
(■) 


Gm. 
280 

549 

621 

440 

466 


437 
485 

(') 

(') 
(') 
(') 

0) 

(■) 


Calor- 
ies. 
2620 

3480 

3980 

3730 
070-, 


3270 
2965 

5500 

4150 

3400 

3050 

2700 
2450 


1: 

4.9 

5.7 

6.2 

7.1 

5.2 

4.9 
5.5 

7.2 

6.2 

6.2 

6.1 

6.1 
6.1 


These  results  may  be  used  to  ascertain  in  a  general  way  the  food 
requirements  of  individuals  when  their  mode  of  living  is  known,  as  in 
institutions.  There  will  be  a  margin  of  error,  but  the  result  will  be 
of  service  in  completing  diets : 


8  hours  of  sleep  at  65  calories    520  calories. 

2  hours'  light  exercise  at  170  calories 340       " 

8  hours'  active  exercise  at  290  calories  2320       " 

6  hours'  sitting  at  rest  at  100  calories 600       " 

Total  food  requirement  for  the  day 3780       " 

(Sherman.) 

The  amount  of  tension  under  which  the  work  is  done  will  have 
something  to  do  with  the  amount  of  food  required.  If  tlie  work  is 
done  with  a  great  deal  of  nervous  energy,  as  in  racing  and  contests 
of  various  kinds,  the  food  requirements  will  be  greater  than  if  the 
work  is  done  slowly  and  under  less  pressure. 

Even  if  no  muscular  work  is  done,  there  will  be  a  certain  amount 

of  food  required  to  maintain  the  body.     Various  estimates  have  been 

1  Fats  and  carbohydrates  in  sufficient  amounts  to  furnish,  together  with  the 
protein,  the  indicated  amount  of  energy. 


METABOLISM  53 

made  as  to  where  this  energy  goes.  Perhaps  the  greatest  demand  is 
to  maintain  muscle-tone  or  muscle-tension,  and  it  is  thought  that  from 
a  third  to  a  half  of  the  energy  required  at  rest  is  utilized  by  this  func- 
tion of  the  body.  This  is  less  during  sleep  than  during  waking  hours. 
The  circulation  takes  5  to  10  per  cent.,  and  respiration  from  10  to  20 
per  cent.,  and  about  8  to  12  per  cent,  are  supposed  to  be  expended 
in  digestion  and  assimilation.  No  very  definite  suggestions  have  been 
made  concerning  the  amount  needed  for  the  work  of  the  secreting 
glands  or  the  nervous  system. 

Metabolism  goes  on  whether  resting  or  working,  and  also  whether 
fasting  or  taking  food.  Metabolism  is  lessened  by  resting,  still  more 
by  sleeping,  and  also  by  starvation,  and  each  day  that  the  fasting 
goes  on  there  is  a  rather  lessened  metabolism.  On  the  whole,  how- 
ever, the  fasting  metabolism  is  rather  constant,  and  the  energy  is 
derived  from  the  tissues  of  the  body.  First,  the  glycogen  is  stored  in 
the  muscles,  and  then  the  body-fat  and  other  structures  of  the  body. 
If  food  is  not  supplied  after  a  certain  length  of  time,  death  ensues. 
If  food  is  given,  the  metabolism  is  raised,  so  that  within  certain  limits 
the  more  food  taken  the  more  will  be  metabolized. 

Requirements  in  Disease. — These  may  vary  greatly  and  we  are 
in  need  of  studies  on  the  nutrition  in  the  various  diseases.  In  some 
conditions,  as  in  fever,  the  metabolism  is  greatly  increased  and  the 
same  is  true  of  Graves'  disease.  In  other  diseases  the  heat  produc- 
tion may  be  below  normal,  due  to  retarded  metabolism ;  examples  of 
this  are  myxedema  and  constitutional  obesity. 

Mental  Work  and  Metabolism. — Curiously  enough,  mental  work 
does  not  apparently  utilize  either  heat  or  energy  in  the  ordinary  way. 
A  man  of  a  high  degree  of  intellect  in  a  respiration  calorimeter  does 
not  cause  any  difference  in  the  registration  by  hard  mental  work, 
such  as  working  out  abstruse  mathematic  problems  requiring  hours 
of  time.  The  same  apparatus,  however,  is  sufficiently  sensitive  to 
register  the  heat  generated  by  turning  over  in  bed  or  by  raising  the 
arm. 

Metabolism  and  Heat. — The  body  heat  is  maintained  at  or  about 
98.2°  F.,  regardless  of  the  external  temperature.  The  heat  is  largely 
regulated  by  the  exercise  of  the  body,  but  in  extremes  the  rate  of  food 
oxidation  may  be  changed.  In  cold  weather  more  food  will  be 
required  than  in  warm. 

Metabolism  and  Fever. — In  febrile  conditions  the  food  require- 
ments of  the  body  are  raised,  and  an  increased  amount  of  food  should 
be  given  to  cover  this.     (See  Feeding  in  Fevers.) 

Climate. — In  cold  climates  fat  and  protein  foods  are  used  more 
largely,  while  in  hot  climates  carbohydrates  are  preferred.  Woodruff 
is  of  the  opinion  that  climate  affects  the  diet,  mainly  by  the  supply 
it  affords. 


54  FOOD  REQUIREMENTS 

Race. — The  food  of  different  races  varies  widely,  but  this  is  due,  for 
the  most  part,  to  the  varying  conditions  under  which  they  live,  and 
especially  to  the  food-supply  that  is  most  available  by  reason  of  cost 
and  the  ease  with  which  it  can  be  procured.  The  Eskimos  subsist 
largely  upon  raw  or  partly  cooked  meat  and  use  large  amounts  of  fat. 
In  the  torrid  zone  the  natives  eat  largely  of  cereals,  fruits  and  vege- 
tables. In  the  temperate  zones  the  diet  is  mixed,  and  is  dependent 
largely  upon  social  and  financial  conditions,  being  of  the  most  varied 
character  in  the  case  of  the  well-to-do,  whereas  among  the  poor  it  is 
apt  to  be  made  up  of  the  cheaper  meats,  breads  and  vegetables.  Sol- 
diers and  travelers  from  the  temperate  zones,  going  either  north  or 
south,  usually  require  approximately  the  same  varieties  of  food  they 
had  at  home.  Soldiers  in  the  tropics  crave  and  eat  meat,  when  they 
can  obtain  it,  and  in  almost  as  large  quantities  as  they  would  at  home, 
and  even  after  years  of  life  in  the  tropics  do  not  make  any  great 
change  in  their  diet. 

Major  Charles  E.  Woodruff,  Surgeon  U.  S.  A.,  expresses  the  fol- 
lowing opinion:  "All  natives  of  the  tropics  (where  civilization  causes 
over-population)  are  in  a  condition  of  nitrogen  starvation  and  need 
much  more  nitrogen  than  they  can  possibly  get.  The  old  standards 
of  teaching  that  we  should  eat  as  the  natives  is  most  vicious.  They 
do  not  eat  meat  because  they  can  not  get  it.  They  crave  it,  need  it, 
and  eat  it  when  they  can.  On  account  of  the  destructive  effects  of 
the  concentrated  tropical  actinic  rays  on  protoplasm  we  need  more 
nitrogen  than  at  home.  Please  don't  copy  the  old  falsehood  that  we 
need  less.  It  is  also  true  that  we  need  fat,  as  it  furnishes  energy  bet- 
ter than  carbohydrates.  It  is  eaten  in  preference  to  starches  and 
sugars  for  this  purpose  by  workers  when  they  can  afford  it,  but  they 
take  to  starch  (rice)  because  it  is  cheaper.  It  is  incorrect  to  say  that 
it  overheats.  It  does  not  overheat  us,  and  it  is  false  to  say  that  fat  is 
not  needed  in  the  tropics. ' ' 

An  interesting  study  of  the  foods  used  by  different  races  of  people 
has  been  made  by  Landis,  of  the  Phipps  Institute  of  Philadelphia. 
The  figures  are  reduced  to  a  per  man  basis,  the  members  of  the  house- 
hold being  rated  in  terms  of  adult  males,  and  children  being  classed 
in  terms  of  fractions  of  the  male  unit. 


-Italian v     , Negro- 


Pamily  C — o  S — o  S — r  B — d  B — t  W — e 

Number    "men"     4.3  7.6  2.6  4.2  2. .5  4.1 

Calories  per  man  per  day 2887.0  2589.9  2605.0  2774.7  3697.3  2138.8 

Cost  food  per  man   per  day.  .  .  $0,158  $0,229  $0,187  $0.21  $0.2496  $0.19 
Calories  for  $.10,  inc.  seasoning 

and    beverages    1813.5  1127.0  1389.0  1317.3  1276.1  1122.1 

Protein    calories    per    man    per 

aay     334.3  355.3  202.1  349.2  356.3  236.9 

Proportion    protein    11.6%  13.7%  7.7%  12.5%  9.6%  11.1% 

Proportion    fat    18.5%  20.8%  19.3%  37.09c  55.4%  31.2% 

Proportion     carbohydrates 69.8%  65.4%  72.9%  50.4%  34.9%  57.6% 


METABOLISM  55 


Italiaa  Negro 


Average  calories  per  ■"man"  per  day 2690.6  2870. ■,' 

Average  cost  per  man  per   day $.191  $.2165 

Average  calories  for  $.10    1443.1  1238.5 

Average  protein  calories  per  man  per  day....  297.2  (74.3  grammes)  314.1  (78.5  grammes) 


, Jewish ,     , Polish ^ 

Family  H — n  C — r  S — r  S — z  D — y  Z — y 

Numoer    "men"     2.5  2.4  2.3  2.9  3.2  2.4 

Calories   per   man   per   day....  2118.05  3279.9  2521.1  3399.64  2997.3  2975!'2 

Cost  food  per  man  per  day ...  .  $0.2238  $0.3041  $0,195  $0.4118  $0,328  $0,321 
Calories  for  $.10,  inc.  seasoning 

and    beverages     946.13  1078.32  1290.6  884.46  970.5  926.7 

Protein   calories   per   man   per 

aay     314.28  406.45  331.3  511.0  420.1  468.3 

Proportion    protein     14.8%  12.4%  13.1%  15.0%  14.1%  12.4% 

Proportion    fat    25.8%  32.0%  24.9%  37.3%  28.8%  25.6% 

Proportion    carbohydrates 59.3%  55.5%  61.9%  47.6%  57.1%  61.9% 

Jewish  Polish 

Average  calories   per   "man"   per   day 2693.7  3124.04 

Average  cost  per  man  per  day $.2409  $.3469 

Average  calories   for   $.10    1105.01  927.22 

Average    protein   calories   per   man    per   day..  350.67  (87.8  grammes)  433.1  (108  grammes) 

Sex. — As  a  rule,  women  eat  and  require  less  food  than  men.  This 
is  largely  due  to  the  indoor  and  sedentary  life  led  by  so  many  women. 
Under  equal  conditions  a  woman  of  the  same  size  requires  the  same 
amount  of  food  as  a  man.  On  an  average,  women  are  only  about  four- 
fifths  as  large  as  men,  and  consequently,  dietaries  for  groups  of 
women  will  require  about  four-fifths  the  amount  of  food. 

Size  and  Weight. — For  adults  living  under  the  same  conditions, 
the  food  requirements  vary  with  the  weight  of  the  individual.  The 
larger  the  bod}'  the  more  food  will  be  required,  but  it  should  be  noted 
that  the  requirement  varies  also  directly  with  the  amount  of  surfaces 
exposed,  so  that  a  small  man,  having  a  relatively  larger  surface,  will 
radiate  more  heat  and  will  require  more  food  per  kilo  than  a  larger 
one.  This  has  been  tested  experimentally  both  in  man  and  in  animals. 
As  very  obese  individuals  have  a  larger  layer  of  fat  which  does  not 
require  as  much  energy  to  maintain  as  muscles,  this  also  makes  a 
difference  in  the  food  requirement.  In  computing  dietaries  these 
facts  are  rarely  taken  into  consideration. 

Food  and  the  Skin  Surface. — Rubner  showed  that  the  amount  of 
food  needed  is  directly  proportional  to  the  superficial  area  of  the  body, 
or  in  other  words,  the  metabolism  varies  in  direct  proportion  to  the 
amount  of  skin  surface.  This  is  due  to  the  fact  that  the  larger  the 
body  the  smaller  is  the  proportion  of  surface  to  the  weight  and  as 
most  of  the  heat  is  lost  from  radiation  from,  the  surface  a  small  sized 
animal  loses  much  more  heat  in  proportion  than  a  large  one.  This 
is  well  illustrated  in  the  caloric  requirements  of  infants.  The  amount 
of  food  required  may  be  estimated  from  the  surface  and  tables  have 
been  worked  out  .showing  the  skin  surface   of  people   of  different 


56 


FOOD  REQUIREMENTS 


heights  and  weights.  DuBois  and  DuBois  (Archives  of  Internal 
Medicine,  1916,  xvii,  855)  have  worked  out  a  method  which  needs 
only  the  height  in  centimeters  and  the  weight  in  kilograms  to  deter- 
mine the  surface  area  in  meters. 


200 

190 

180 
en 

Sl70 

»— 

1160 
2150 
.^140 

CD 

c:i30 

120 


20 


30 


40 


50 


60 


70 


80 


90 


100      no 


100 


16 

1.7 
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20 

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200 
190 
180 
170 
160 
150 
140 
130 
120 


20 


30 


40 


50         80         70         80 
WEIGHT-KILOGRAMS 


90 


100 


no 


100 


Cliart  for  determining  surface  area  of  man  in  square  meters  from  weight  in 
kilograms  (Wt.)  and  height  in  centimeters  (Ht.)  according  to  the  formula: 
Area    (Sq.  Cm.)  =  Wt.0.425  x  Ht.0.75  x  71.84. 

-3 

A  formula  devised  by  Meehs  and  frequently  used  is  S  =  C  -^   W^ 

where  S  is  surface,  W  weight,  and  C  a  constant  dependent  upon  the 

shape  and  density  of  the  solids ;  for  man  C  is  12.3. 


Percentage  Increase  or  Decrease  in  the   Hourly  Basal  Metabolism  for   Various 

Factors  affecting  the  Extent  of  Energy  Metabolism    (as  adapted  by 

Carter  from  the  work  of  Lusk  and  Du  Bois ) . 

Increase  or  decrease  Additional  calories 

Average  man,  154  i)ounds,     (70  kg.)                                percent.  per  hour  for 

at  complete  rest.  70  Calories  ,     average  man. 
per  hour :                                                                               Increase. 

Ingestion  of  food   5  to  10  4  to  7 

Lying  in  a  chair,  supported 0  0 

Sitting  up  in  a  chair 8  6 

Moderate  activity  in  chair 29  20 

Very  restless  in  bed   20  to  100  14  to  70 

Exercise : 

Walking  on  level,  2.7  miles  per  hour.  .  .  .                230  160 

Climbing,  2.7  miles  per  hour    580  407 

Hard  labor,  bicycle  riding  756  529 

Tliin  but  healthy 0  0 

Fat  but  healthy 0  0 

Disease : 

Most  patients  not  seriously  ill   +  10  to  —  10  +  7  to  — 7 

Obesity     +  10  to  —  10  +  7  to  —  7 

Diabetes  with  severe  acidosis   0  to  15  0  to  10 

Severe  pernicious  anemia 0  to  20  0  to  14 


Additional  calories 
Increase  or  decrease              per  hour  for 
per  cent.                       average  man. 

Increase. 
0  to  30                         0  to  21 

20 

to 

40 

14 

to 

28 

30 

to 

60 

21 

to 

42 

40 

to 

50 

28 

to 

35 

10 

to 

20 

7 

to 

14 

25 

to 

Decrease. 
50                          18 

to 

35 

75 

to 

100 

53 

to 

70 

—  10 

to 

—  30 

—  7 

to 

—  21 

—  10 

to 

—  35 

—  7 

to 

—  25 

—  25 

to 

—  50 

—  18 

to 

—  35 

METABOLISM  57 


Acromegaly    

Cancer,  severe  heart  and  kidney  disease 

and  high  fever   

Leukemia     

Typhoid  fever   

Convalescence    

Exolphthalmic  goitre : 

Mild    

Severe     

Prolonged  undernutrition    

Diabetes,   emaciated    

Cretinism  and  mj-Tcedema   

Example. — A  man  of  50  years,  weight  70  kilos  (153  poimds),  height  17  cm.  (67 
inches),  in  bed  8  hours,  walks  1  hour,  sits  about  or  office  work  14  hours,  hard 
exercise  1  hour. 

Calories 
per  hour. 

a.  Area,  1.8  square  meters 

b.  Basal  metabolism  per  square  meter   35.2 

c.  Individual  basal  metabolism  1.8  X  35.2  63.3 

(Fractions   are  usually  disregarded) 

d.  Increase  for  food  ingestion  10  per  cent,   (in  all  calculations)  63  X  0.1  .  .  .  6.3 

e.  While  in  bed   (c  +  d)    63  +  6    69 

f.  Increase  for  office,  etc.,  29  per  cent.  63  X  0.29   18 

g.  Increase  for  walking  230  per  cent.  63  X  2.3   145 

h.  Increase  for  hard  exercise  756  per  cent.  63  X  7.56   476 

Calories 
per  dav. 

8   hours   in   bed   69  X  8    552 

14  hours  sedentary  69  +  18  X  14 1218 

1    hour   walking  69  +  145    214 

1  hour  hard  exercise  69  +  476  545 

Total  per  day   2529 

As  to  the  loss  of  heat  from  the  body  it  has  been  estimated  that  87.5 
per  cent,  is  lost  by  surface  radiation,  10.7  per  cent,  through  the  lungs, 
and  1.8  per  cent,  through  excretions. 

Photographic  Method  of  Measuring  the  Surface  Area  of  the 
Body. — Benedict  (The  American  Journal  of  Physiology,  1916,  xli, 
275)  has  developed  a  simple  method  based  on  computations  made 
of  certain  definite  photographic  poses  (particularly  the  side  view  with 
the  arm  extended)  that  when  compared  with  the  results  obtained  by 
DuBois'  linear  formula,  is  strikingly  accurate. 

Age. — For  the  reason  given  above,  and  also  due  to  differences  in 
metabolism  and  owing  to  the  influences  of  growth,  the  food  require- 
ments of  the  young  is  greater  per  kilo  of  body-weight  than  in  adults. 
The  food  requirements  during  the  first  three  months  is  100  calories  per 
kilo  (45.4  per  pound)  ;  during  the  second  three  months  it  is  between 
100  and  90  per  kilo  (40.9  per  pound)  ;  during  the  latter  half  of  the 
first  year  it  sinks,  to  80  per  kilo  (36.4  per  pound).  Artificially  fed 
children  are  thought  to  require  slightly  more  than  breast-fed  children. 

Gephart  and  DuBois    (Archives  of  Internal  Medicine,  1916,  xvii, 


58 


FOOD  REQUIREMENTS 


p.  913)  have  the  following  standards  of  normal  metabolism  per  hour 
per  square  meter  of  body  surface. 

Standards  of  Normal  Metabolism.     Average  Calories  per  Hour  per  Square 
Meter  of  Body  Surface. 

o„h;a/.t  According      According  to  linear 

Boys,  twelve  to  thirteen  45.7  49.9 

Men,  twenty  to  fifty   34.7  39.7 

Women,  twenty  to  fifty 32.3  36.9 

Men,  fifty  to  sixty   30.8  35.2 

Women,  fifty  to  sixty 28.7  32.7 


Cau 

.•• 

\ 

1 — 

50 

/ 

\ 

^-^ 

\ 

40 

^ 

_= 

30 

20 

10 

n 

YRsTlO       20       30       40       50       60       70       80 
CAL.  P[R  SQUARE  UIKR  P[R  HOUR. 

This  chart,  prepared  by  Du  Bois,  shows  the  basal  metabolism  as  measured  in 
calories  produced  per  square  meter  of  body  surface  per  hour  from  birth  until 
the  age  of  eighty-five  years  in  human  males.  Between  maturity  and  the  eighty- 
fifth  year  there  is  a  gradual  fall  in  the  intensity  of  metabolism  of  13  per  cent. 

In  computing  dietaries  for  children  the  following  tables  of  Gillett 
will  be  found  useful : 

Calorie  Requirement  of  Children  at  Different  Ages. 

Age,  Years  , Calories v 

Boys.  Grirls. 

From     2  to  5    1,309  1,245 

From     6  to  9      1,797  1,575 

From  10  to  13    2.337  2,015 

From   14  to  17    2.534  2,253 


Food  Allowances  for  Children. 

. Calories  per 

Age,  Years  Boys. 

Under   2    000-1,200 

From     2  to     3    1,000-1,.300 

From     3  to     4    1 ,100-1,400 

From     4  to     5    1,200-1,500 

From     5  to     6    1,300-1,600 

From     6  to     7 1,400-1.700 

From     7  to     8     1..500-1,800 

From     8  to     9    1,600-1.900 

From     9  to  10    1,700-2,000 


dav 

Girli 

900-1 
980-1 
1.060-1 
1.140-1 
1.220-1 
1,300-1 
1.380-1 
1.460-1 
1,550-1 


.200 
,280 
,360 
,440 
.520 
.600 
,680 
,760 
,850 


METABOLISM  59 

From  10  to  11  1,900-2,200  1,650-1,950 

From  1 1  to  12  2,100-2,400  1,750-2,050 

From  12  to  13  2,300-2,700  1,850-2,150 

From  13  to  14  2,500-2,900  1,950-2,250 

From   14  to  15  2,600-3,100  2,050-2,350 

From  15  to  16  2,700-3,300  2,150-2,450 

From  16  to  17  2,700-3,400  2,250-2,550 

Care  should  be  taken  to  individualize  and  active  children  require 
more  than  sedentary  ones.  In  boys '  schools  and  out-of-doors  in  camp 
the  amount  actually  consumed  and  needed  is  between  4000  and  4500 
calories  per  day.  (See  Feeding  of  School  Children).  It  is  interest- 
ing to  compare  these  figures  with  the  earlier  ones.  Atwater  allow- 
ances are  as  follows : 

Boy  15  to   16  years  requires  0.9  the  food  of  a  man  at  moderate  work. 


Girl   15-16 

0.8 

Boy  13-14 

0.8 

Girl   13-14 

0.7 

Boy   12 

0.7 

Girl   10-12 

0.6 

Bov   10-11 

0.6 

Child   6-9 

0.5 

Child   2-5 

0.4 

Child  under  2 

0.3 

Sherman  has  approximated  the  average  amounts  as  follows : 

Boys  of  14-17 2500-3000  calories. 

Girls  of  14-17     2200-2600       " 

Children  of  10-13     1800-2200       " 

Children  of  6-9     1400-2000       " 

Children  of  2-5     1200-1500       " 

Children  of  1-2     900-1200       " 

Based  on  the  amount  per  kilo : 

Under  1  year   100  calories  per  kilo. 

Under   1-2  years   100-90 

Under  2-5  years 90-80  "                   " 

Under  6-9  vears 80-70  "                   " 

Under  10-13  years 70-60  "                   " 

Under  14-17  years 60-45 

For  the  very  young  his  estimate  is  somewhat  larger  than  those  made 
by  Camerer,  Heubner,  and  others. 

After  middle  age  is  passed  the  food  requirement  diminishes,  and  in 
old.  age  it  is  considerably  less,  owing  to  the  lessened  exercise  and  the 
lower  ratio  of  metabolism.  Without  muscular  labor  the  requirement 
per  kilo  has  been  estimated  at  sixty  years  of  age  at  34  calories  per 
kilo,  and  at  eighty  years  of  age  at  27  calories  per  kilo. 

Nutrition  and  Growth. — Interesting  studies  have  been  made  by 
Mendel  and  others.  Growth  depends  on  an  inherited  capacity  to 
grow,  a  factor  that  cannot  be  modified  at  present,  and  on  nutrition 
and  environment,  which  are  capable  of  control.     The  nutrition  may  be 


60  FOOD  REQUIREMENTS 

perfect  and  still  abnormalities  in  growth  occur,  and  on  the  other  hand, 
the  food  may  be  more  or  less  faulty  or  deficient  without  interfering 
greatly  with  the  capacity  to  grow,  even  though  what  we  term  disease 
conditions  are  present. 

It  is  an  interesting  fact  that  increasing  the  total  amount  of  the  pro- 
tein in  the  diet  does  not  force  the  growth  nor  make  it  go  beyond  the 
normal  limits,  although  too  great  restrictions  may  interfere  with 
growth,  which  begins  again  or  increases  when  sufficient  protein  is  sup- 
plied. Mendel  and  others  have  called  attention  to  the  importance 
of  considering  not  the  proteins  as  such,  but  their  amino-acid  content  in 
relation  to  growth.  By  feeding  experiments  on  animals  they  have 
tested  various  isolated  proteins,  in  connection  with  the  necessary  car- 
bohydrates, salts  and  fats  and  find  that  certain  proteins  permit  of 
growth,  as  adestin,  globulin,  excelsin,  glutelin  and  others  of  vegetable 
origin,  and  casein,  lactalbumin  and  others  of  animal  origin,  and  that 
failure  to  induce  growth  resulted  from  the  use  of  gelatin,  legumin, 
conglutin  and  others.  The  failure  can  be  traced  back  to  the  absence 
of  certain  essential  amino-acids,  for  example,  gelatin  and  zein  lack 
the  tryptophan  group.  In  cases  where  these  are  lacking  and  causing 
failure  to  grow,  the  addition  of  tryptophan  as  such  results  in  mainte- 
nance, but  no  growth  which,  however,  ensued  on  the  addition  of  lysin. 
The  future  study  of  foods  along  this  line  will  undoubtedly  solve  many 
of  the  problems  in  feeding,  especially  in  infants  and  animals. 

There  has  been  an  enormous  amount  written  about  the  different 
carbohydrates,  so  necessary  for  nutrition  and  growth,  but  at  the 
present  time  one  cannot  state  which  ones  are  best.  Lactose  is  the 
form  supplied  in  the  milk  for  the  growing  young  and  would  seem  to 
be  the  best  for  growth  in  early  life,  but  other  sugars  and  starches 
have  been  highly  recommended  by  pediatrists.  The  indispensability 
of  true  fats  and  lipoids  to  growth  has  not  been  proven,  but  the  fatty 
foods  contain  substances  that  are  necessary  for  nutrition  and  growth. 
(See  Vitamins.)  Investigation  by  numerous  observers  seems  to  show 
that  the  administration  of  cod  liver  oil,  egg  yolk  and  unwashed  butter 
to  undernourished  infants  and  children  rests  on  a  sound  foundation. 

Striking  observations  have  also  been  made  on  the  failure  of  growth 
when  the  mineral  salts  were  insufficient,  even  though  the  remainder  of 
the  diet  was  adequate. 

Protein  Requirements. — Having  considered  the  total  amount  of 
food  required,  the  next  question  is  to  determine  how  much  protein, 
fat,  and  carbohydrate  shall  be  used  to  furnish  the  requisite  number  of 
calories.  There  is  a  great  deal  of  difference  of  opinion  on  this  subject. 
At  the  present  time  there  is  considerable  known  concerning  the  mini- 
mum amount  of  protein  required,  and  the  maximum  that  can  be 
metabolized  without  producing  deleterious  results.  The  protein 
optimum  or  the  amount  on  which  the  body  does  best  is  still  an  open 
question. 


METABOLISM  61 

There  are  several  ways  of  taking  up  the  subject.  Voit  and  many 
others  have  studied  the  food  taken  by  various  individuals,  and  he 
found  that  an  average  sized  man  at  moderate  work  took  about  118 
grams  of  protein  together  with  some  56  grams  of  fat  and  500  grams 
of  carbohydrates.  This  represents  some  18.8  grams  of  nitrogen. 
This  amount  was  formerly  regarded  as  a  standard,  but  more  recently 
there  is  a  tendency  to  lessen  the  protein  to  100  grams  or  less.  Voit's 
standard  is  a  liberal  one,  which  need  only  be  exceeded  in  some  forms 
of  tuberculosis  and  some  other  diseases,  and  which  may  be  diminished 
in  many  diseased  conditions  to  great  advantage,  as  in  gout  and 
nephritis.  The  protein  needs  of  the  body  will  be  more  clearly  under- 
stood by  considering  nitrogen  metabolism. 

Nitrogen  Equilibrium. — It  has  been  found  in  normal  individuals 
that  nitrogen  equilibrium  can  be  maintained  on  various  amounts  of 
protein  food.  This  is  determined  by  comparing  the  total  amount 
ingested  with  the  total  amount  excreted,  or  by  making  the  comparison 
of  that  absorbed  with  that  which  is  utilized  and  excreted  in  the  urine. 
If  the  amounts  correspond  or  nearly  so  the  body  is  said  to  be  in  a  state 
of  nitrogen  equilibrium.  The  total  amount  of  food  required  is  gov- 
erned largely  by  the  exercise  taken.  It  does  not  seem  to  matter  so 
much  what  form  the  food  is  taken  in,  so  long  as  it  can  be  utilized. 
The  protein  metabolism,  however,  does  not  depend  so  much  on  the 
amount  of  exercise  as  it  does  on  the  food  taken.  If  small  amounts 
of  protein  are  given,  equilibrium  may  be  established  at  a  low  level, 
and  if  large  amounts  are  given,  at  a  high  level.  Thus  Chittenden  was 
able  to  maintain  health  and  strength  on  as  little  as  50  grams  protein 
a  day,  and,  on  the  other  hand,  nitrogen  equilibrium  has  been  estab- 
lished on  as  much  as  150  grams  a  day  and  even  200  grams.  The  body 
is  able  to  regulate  the  amount  metabolized  by  the  amount  taken.  If 
the  body  is  not  in  a  state  of  equilibrium  it  is  either  excreting  more  or 
less  than  is  being  ingested.  In  starvation,  when  none  is  supplied,  it 
has  been  found  that  protein  metabolism  goes  on  about  the  same  as 
when  food  is  given,  only  that  the  total  energy  must  be  derived  from 
the  body  itself.  It  has  been  estimated  that  13  per  cent,  is  furnished 
by  the  body-protein  and  87  by  the  body-fat.  A  man  at  light  work 
starving  in  a  calorimeter  was  found  to  be  using  1971  calories,  or  31.23 
per  kilo  of  body-weight ;  71.7  grams  of  protein  were  oxidized,  and 
181.2  grams  of  fat.  In  the  first  few  days  of  fasting  the  nitrogen  ex- 
cretion is  small,  as  there  is  a  certain  amount  of  glycogen  which  is 
stored  in  the  body,  and  this  is  metabolized  in  place  of  the  protein  and 
so  spares  it.  It  has  been  found  in  lean  animals  later  on  in  fasting 
that  more  protein  is  used  in  maintaining  the  body  than  in  fat  animals. 
In  the  fat  animals  the  fat  is  used  to  a  greater  extent,  and  the  fat  may 
be  regarded  as  sparing  or  protecting  the  protein. 

The  effect  of  carbohydrate  and  fats  in  protecting  the  body-protein 
holds  good  in  feeding.     If  a  diet  is  used  which  is  low  in  protein. 


62  FOOD  REQUIREMENTS 

nitrogen  equilibrium  may  be  attained  by  adding  either  fats  or  carbo- 
hydrates to  the  diet,  providing,  of  course,  the  protein  intake  does  not 
fall  below  the  minimum  requirement.  There  may  be  a  nitrogen  loss 
when  the  total  amount  of  food  taken  is  below  the  requirement  of  the 
body,  and  this  loss  may  be  prevented  by  adding  either  carbohydrate 
or  fat  to  bring  it  up  to  the  standard.  This  is  due  to  the  fact  that 
if  the  total  of  food  supplied  is  too  low,  some  of  the  body-protein  is 
used  to  make  up  the  deticiency.  Gelatin  may  also  be  used  as  a  sparer 
or  protector  of  protein,  100  grams  of  gelatin  being  equivalent  to 
about  35  grams  of  protein.  It  does  not  protect  as  well  as  either  carbo- 
hydrate or  fat.  The  nitrogen  equilibrium  is  best  maintained  on  a 
mixed  diet,  containing  in  addition  to  the  protein  both  fat  and  carbo- 
hydrate. If  the  carbohydrate  is  out  of  the  diet  there  will  be  a 
nitrogen  loss,  owing  to  the  fact  that  there  must  always  be  a  certaiii 
amount  of  glucose  in  the  blood,  and  if  this  cannot  be  supplied  from 
the  carbohydrate  of  the  food  it  will  be  formed  from  the  body-protein. 

It  should  be  borne  in  mind  that  it  takes  some  days  to  establish  a 
nitrogen  equilibrium  when  the  customary  diet  is  changed.  If  the 
usual  diet  of  an  individual  contains  16  grams  of  nitrogen,  and  the 
diet  is  suddenly  changed,  it  will  be  several  days  before  equilibrium 
is  established  at  the  new  level,  whether  it  be  above  or  below  the 
amount  usually  metabolized.  There  will  be  slight  losses  of  a  transient 
character  if  somewhat  less  than  usual  is  taken,  but  if  the  loss  persists 
it  means  that  either  too  little  protein  is  being  taken  in  the  food,  or 
that  the  total  caloric  value  of  the  food  is  below  the  amount  required, 
or  that  the  body  is  affected  with  some  disease  attended  with  a  loss  of 
nitrogen,  i.  e.,  some  wasting  disease. 

If  the  nitrogen  balance  is  disturbed  so  there  is  a  plus  balance, 
it  means  that  nitrogen  is  being  stored  in  the  body.  This  occurs  nor- 
mally in  young  animals  which  are  growing,  in  pregnancy,  as  the 
result  of  exercise  that  causes  an  increase  in  the  size  of  the  muscles, 
and  in  those  who  have  had  some  disease  where  they  have  lost  flesh  ami 
are  regaining  their  normal  weight. 

Low  Protein  Standards. — Chittenden  and  his  followers  believe 
that  the  best  diet  is  that  which  contains  but  little  protein  above  the 
minimum,  together  with  fat  and  carbohydrates  to  cover  the  needed 
calories.  They  urge  that  on  this  diet  one  may  maintain  health  and 
weight,  and  that  the  mental  and  physical  efficiency  is  greater  than 
when  more  liberal  diets  are  taken.  They  believe  that  as  the  proteins 
are  oxidized  with  the  formation  of  end-products  more  or  less  difficult 
of  excretion,  that  any  protein  over  the  minimum  requirement  adds 
to  the  wear  and  tear  of  the  body  without  increasing  its  efficiency. 
Chittenden's  experiments  included  college  professors  and  instructors, 
representing  mental  workers;  United  States  soldiers,  representing 
physical  workers;  college  students,  representing  a  combination  of 
mental  and  physical  workers.     The  experiments  covered  sufficiently 


METABOLISM  t)3 

long  times,  and  it  was  found  that  nitrogen  equilibrium  could  be  main- 
tained on  6  to  9  grams  of  nitrogen  instead  of  the  16  or  more  usually 
taken  b}^  the  average  individuals.  Fats  and  carbohydrates  were  added 
to  bring  the  food-value  up  to  2500  or  2600  calories  per  day.  This 
total  would  seem  to  be  too  low  for  men  doing  more  than  rather  light 
work,  whatever  might  be  said  of  the  protein  content. 

Value  of  Low  Protein  Diet. — Chittenden's  experiments  are  of  enor- 
mous practical  value  in  showing  that  a  low  protein  diet  can  be  used 
over  long  periods  of  time  without  danger.  Diets  low  in  protein  are  of 
value  in  gout  and  gouty  affections,  in  some  skin  diseases  accompanying 
disorders  of  metabolism,  in  treating  the  ill-effects  of  habitual  over- 
eating in  arteriosclerosis,  in  fevers  and  other  affections.  Brain- 
workers  and  those  leading  sedentary  lives  will  also  doubtless  do  better 
on  diets  lower  in  protein  than  those  usually  taken. 

Objections  to  Low  Protein  Diet. — Many  objections  have  been  urged 
against  this  low  standard  of  Chittenden.  Perhaps  the  chief  objection 
is  that  the  human  race  has  automatically  arrived  at  the  diets  usually 
taken  after  centuries  of  eating,  and  that  people  in  general  apparently 
do  not  suffer  from  diets  reasonably  high  in  protein. 

Some  have  believed  that  while  a  low  protein  diet  may  be  of  great 
value  over  short  periods  of  time,  the  prolonged  use  may  render  the 
body  less  resistant  to  infection  or  possibly  cause  ultimate  disturbances 
in  metabolism.  Those  accustomed  by  habit  to  low  protein  diet  may 
have  difficulty  in  utilizing  larger  amounts  should  greater  demands  be 
made  upon  the  body. 

In  very  hard  work  the  fat  and  carbohydrate  necessary  may  mean 
undesirable  bulk  and  strain  on  the  digestive  organs,  not  to  mention 
the  less  pleasing  taste. 

Another  much  used  argument  is  that  all  successful  races  are  meat 
eaters,  but  as  a  meat  diet  is  expensive  it  may  mean  that  the  successful 
being  able  to  buy  meat  prefers  to  eat  it  just  as  the  rich  consume  expen- 
sive alcoholic  drinks. 

As  a  matter  of  fact  the  great  majority  of  the  human  race  will  go  on 
eating  and  drinking,  according  to  their  appetites  and  their  means  of 
gratifying  them.  Yet  the  problem  is  one  which  is  of  the  highest 
human  interest,  especially  in  connection  with  the  dieting  in  disease 
and  in  preventing  it  when  danger  has  been  anticipated.  It  is  inter- 
esting to  compare  the  navy  diets  made  high  in  protein,  because  the 
sailor  wants  it  and  is  happier  and  more  contented  and  does  better 
work  than  the  crew  on  a  perhaps  more  healthful,  but  less  appetizing 
diet. 

The  High  Protein  Diet. — High  protein  diets — those  over  120 
grams — may  be  of  use  in  certain  conditions  during  pregnancy  and 
lactation,  in  convalescing  from  wasting  diseases,  and  in  beginning, 
certainly,  of  physical  training  when  muscle  growth  is  great,  and  in 
combating  certain  diseases,  as  tuberculosis.     During  growth  the  pro- 


64  FOOD  REQUIREMENTS 

tein  requirements  are  higher  than  when  adult  life  has  been  reached. 

High  protein  diets  are  objectionable  in  the  sedentary  and  in  all  of 
those  conditions  indicated  as  doing  best  on  low  protein  diet,  and  in 
general  it  may  be  stated  that  unless  one  has  a  definite  reason  for  doing 
so,  the  protein  need  not  exceed  the  Voit  standard. 

The  Protein  Optimum. — This  is  an  open  question.  As  just  stated, 
the  protein  need  ordinarily  not  go  above  120  grams  for  the  average 
individual,  nor  under  60  grams.  This  leaves  a  rather  wide  range,  and 
it  is  safe  to  say  that  the  optimum  lies  between  those  two,  and  it  will 
undoubtedly  be  found  to  vary  with  the  individual  and  the  conditions 
under  which  he  lives.  We  do  not  believe  that  any  standard  will 
ever  be  fixed  that  will  be  of  universal  application,  but  we  do  think 
that  in  the  future  standards  will  be  worked  out  to  cover  the  various 
classes  of  normal  conditions  and  the  different  disturbances  of  metabo- 
lism. Thus:  In  tuberculosis,  30  per  cent,  above  the  normal  of  the 
given  individual ;  in  nephritis,  60  or  70  grams  daily ;  in  fevers,  70 
grams,  etc.,  are  standards  that  are  being  put  in  practical  use.  Dietary 
standards  have  received  general  attention  for  such  a  short  time  that 
much  may  be  expected  along  this  line  even  in  the  near  future. 

The  Amino-acids. — The  problem  of  protein  is  not  limited  to  the 
amount.  The  nature  of  the  protein  used  is  of  the  utmost  importance 
and  just  beginning  to  be  understood.  Proteins  are  exceedingly  diffi- 
cult of  analysis,  but  chemists  have  succeeded  in  finding  out  that  pro- 
teins are  made  up  of  the  amino-acids,  each  protein  containing  various 
amino-acids  in  various  amounts.  The  following  table  shows  the  com- 
position of  some  of  the  proteins  used  for  food : 

Quantitative  Comparison  of  Amino-Acids  Obtained  by  Hydrolysis  f"om  Proteins. 
(Compiled  by  T.  B.  Osborne,  l'J14)  i 

Oval-  Legumin 

Casein.         bumin.       Gliadin.  Zein.         Edestin.      (Pea) 

Glycocoll    0.00  0.00  0.00  0.00  3.80  0.38 

Alanin    1.50  2.22  2.00  13.39  3.60  2.08 

Valin     7.20  2.50  3.34  1.88  6.20  ? 

Leiicin     ,.  9.35  10.71  6.62  19.55  14.50  8.00 

Prolin    6.70  3.56  13.22  9.04  4.10  3.22 

Oxyprolin    0.23  ?  ?                 ?                 ?  ? 

Phenylalanin    3.20  5.07  2.35  6.55  3.09  3.75 

Glutaminic  acid    15.55  9.10  43.66  26.17  18.74  13.80 

Aspartic   acid    1.39  2.20  0.58  1.71  4.50  5.30 

Serin    0.50  ?  0.13  1.02  0.33  0.53 

Tyrosin    4.50  1.77  1.61  3.55  2.13  1.55 

Cvstin    ?  ?  0.45              ?  1.00  ? 

Histidin    2.50  1.71  1.49  0.82  2.19  2.42 

Arginin     3.81  4.91  2.91  1.55  14.17  10.12 

Lysin     5.95  3.76  0.15  0.00  1.65  4.29 

Trvtophan,  about 1.50  present  1.00           0.00  present  present 

Ammonia    1.61  1.34  5.22  3.64  2.28  1.99 

65.49         48.85         84.73         88.87         82.28         57.43 

1  These  analyses  are  combinations  of  what  appear  to  be  the  best  determinations 
of  various  chemists. 


METABOLISM  65 

Van  Slyke  has  summarized  the  results  of  the  various  investigators 
from  Spallauzani  and  Beaumont  to  Cohnheim,  and  we  have  con- 
densed somewrhat  his  statement  which  is  as  follows:  "The  proteins 
enter  the  stomach  and  are  digested  to  albumoses,  that  is,  the  lon<j: 
protein  chain  of  amino-acids  is  broken  into  somewhat  shorter,  but  still 
somewhat  long  chains,  and  the  protein,  which  is  usually  insoluble,  is 
transformed  into  albumoses.  The  latter  are  not  absorbed,  however. 
The  albumoses  all  pass  down  into  the  intestines  where  they  meet  the 
pancreatic  juice  and  are  split  into  short  chains  of  two  or  three 
amino-acids  each,  and  partly  entirely  to  free  amino-acids.  That  free 
amino-acids  constitute  a  considerable  part  of  the  products  of  intes- 
tinal digestion  was  demonstrated  by  Abderhalden,  who  isolated  most 
of  the  known  amino-acids  from  intestinal  contents.  White  and  Van 
Slyke  have  shown  that  the  entire  mass  of  products,  aside  from  the 
free  amino-acids,  consists  of  short  chain  peptids.  •  Finally,  either  be- 
fore or  after  entering  the  intestinal  wall,  the  products  encounter  a 
third  hydrolytic  enzyme,  erepsin,  which  is  capable  of  carrying  the 
hydrolysis  to  the  stage  of  amino-acids  still  nearer  completion." 

Van  Sl3^ke  traces  the  amino-acids  through  the  body  as  follows: 
' '  Entering  the  alimentary  tract  as  part  of  a  protein  molecule,  it  is  set 
free  by  digestive  hydrolysis  and"  passes  into  the  portal  blood  stream. 
It  may  be  at  once  picked  up  by  the  liver  and  decomposed  into  urea, 
or  perhaps  synthesized  into  reserve  protein.  It  may,  however,  pass 
by  the  liver  and  be  absorbed  from  the  blood  by  one  of  the  other  tissues. 
Here  it  may  remain  for  a  time  before  being  incorporated  into  the 
tissue  protein.  The  fact  that  a  considerable  store  of  amino-acids 
is  always  found  in  the  tissues  is  proof  that  chemical  incorporation 
does  not  instantly  follow  absorption  from  the  blood  stream.  After  a 
period  of  time,  concerning  the  length  of  which  we  are  absolutely 
ignorant,  the  tissue  autolyzes,  and  the  amino-acid  returns  to  the  depot 
of  free  amino-acids  held  by  the  tissue.  From  this  depot  it  may  pass 
back  into  the  blood,  be  taken  out  by  the  liver,  and  destroyed.  Or  it 
may  be  reincarnated  into  a  new  protein  in  some  other  organ." 

The  amino-acids  have  been  likened  to  building  stones.  The  proteins 
taken  into  the  body  as  foods  in  the  process  of  digestion  are  split  into 
their  component  amino-acids  and  these  are  absorbed  and  circulate  in 
the  blood  where  they  are  used  by  the  various  tissues  for  growth  and 
repair.  The  amino-acids  have  also  been  likened  to  the  alphabet,  and 
the  various  proteins  to  words.  Just  as  certain  letters  are  necessary 
to  spell  certain  words,  so  certain  amino-acids  are  required  to  form  the 
various  proteins.  Gelatin  contains  a  large  amount  of  glycocoll,  but  is 
lacking  in  tyrosin  and  tryptophan.  Voit  and  Munk  demonstrated 
that  gelatin  could  not  support  nitrogen  equilibrium,  but  it  was 
shown  later  that  by  the  addition  of  tyrosin  and  tryptophan  nitrogen 
equilibrium  could  be  established  at  least  for  a  short  time. 

It  is  evident  from  experimental  work  that  it  must  be  determined 
5 


66  FOOD  REQUIREMENTS 

which  animo-acids  are  indispensable  and  which  are  not.  Some  of 
them  can  evidently  be  formed  by  synthesis  in  the  body,  as  for  ex- 
ample glycocoll.  In  mammals  tryptophan  seems  to  be  indispensable 
and  it  apparently  cannot  be  formed,  or  at  least  not  in  sufficient^ 
amounts  in  the  body. 

Osborne  and  Mendel  have  studied  certain  proteins  in  their  relation 
to  the  growth  of  young  animals.  They  failed  to  induce  growth  with 
legumelin  (soy  bean),  vignin  (vetch),  giiadin  (wheat  or  rye),  legumin 
(pea),  legumin  (vetch),  hordein  (barley),  conglutin  (blue  or  yellow 
lupin),  gelatin  (horn),  zein  (maize),  phaseolin  (white  kidney  bean). 

In  some  of  these  the  failure  was  evidently  due  to  a  lack  of  certain 
amino-acids  in  the  diet.  The  gelatin  is  explained  above  and  zein 
lacks  tryptophan  and  lysin.  If  large  amounts  of  protein  are  used 
certain  deficiencies  may  not  be  apparent,  but  these  appear  on  restrict- 
ing the  amounts.  Eventually  the  nature  and  functions  of  the  various 
amino-acids  may  be  sufficiently  well  known  to  definitely  influence 
human  dietetics.  This,  and  the  observations  on  vitamins  make  the 
desirability  of  a  mixed  diet  of  fresh  foods  plain. 

The  amino-acids  maj^  be  acted  upon  by  the  intestinal  bacteria  with 
the  formation  of  indol,  skatol,  and  other  substances  which  may  be 
highly  poisonous.  These  are  most  likely  to  be  formed  in  diseases  like 
cholera,  summer  diarrhea,  and  the  like.  Ptomaine  poisoning  is  of  this 
nature.  Carbohydrates  may  be  formed  in  the  body  by  the  synthesis 
of  certain  of  the  amino-acids. 

In  some  diseased  conditions  some  of  the  amino-acids  may  be  excreted 
in  the  urine,  as  the  proteins  are  disintegrated  faster  than  the  amino- 
acids  can  be  metabolized.  In  acute  yellow  atrophy  of  the  liver  and  in 
phosphorovis  poisoning  leucin,  tyrosin,  glycocoll  and  phenylalanin 
may  be  found.  In  some  other  conditions  the  bodj^  loses  the  power  to 
deaminize  and  oxidize  one  or  more  of  the  amino-acids,  as  in  alkapto- 
nuria.    (See  also  Acidosis.) 

Purin  Metabolism  (see  also  Gout). — Some  j^ears  ago  the  proteins 
containing  CjN^  began  to  attract  attention.  These  substances  are 
called  the  purin  bases,  and  are  a  series  of  compounds  called  adenin, 
guanin,  hypoxanthin,  xanthin,  and  uric  acid.  These  substances  occur 
in  foods,  such  as  liver,  pancreas,  and  meats,  in  which  they  or  their 
precursors  are  in  the  nuclear  protein.  They  also  are  found  in  legumes 
and  certain  other  foods. 

A  man  on  a  diet  free  from  purin  excretes  0.3  or  0.4  gram  of  uric 
acid  daily.  This  is  formed  from  the  breaking  down  of  the  nuclei, 
and  is  called  the  endogenous  purin.  That  which  is  in  the  body  as  a 
result  of  metabolism  of  food  is  called  exogenous  purin.  This  latter, 
of  course,  can  be  regulated  to  a  large  extent  by  the  proper  selection  of 
the  diet.  Those  purin  bases  are  difficult  of  excretion,  and  in  certain 
diseases  there  may  be  purin  retention  if  the  amount  is  too  high  (see 
Gout).     In  certain  other  diseases  (as  nephritis)  it  is  a  good  thing  to 


METABOLISM 


67 


Meais. 

Nitrogen  bases 

In  100  grains.  in  grams. 

Beef 0.037 

Calf  meat 0.038 

Mutton 0.026 

Pork 0.041 

Cooked  ham 0.025 

Raw  pork 0.024 

Salmon 0.017 

Tongue  (calf) 0.055 

Liver  sausage 0.038 

Brunswig  sausage 0.010 

Mortadel  sausage 0.012 

Salami  sausage 0.023 

Blood  sausage 

Pig  brain 0.028 

Liver 0.093 

Kidney 0.080 

Thymis 0.330 

Liver  (calf) 0.052 

Chicken 0.029 

Pigeon 0.058 

Goose 0.033 

Deer 0.039 

Young  pheasant 0.034 

Bouillon   (100    gm.),   Beef  tea, 

boiled  two  houi-s 0.015 

Fish. 

Shellfish 0.039 

Tench 0.027 

Codfish 0.038 

Eel 0.027 

Salmon  (fresh) 0.024 

Carp 0.054 

Perch 0.045 

Pike 0.048 

Red  herring 0.028 

Herring 0.069 

Trout 0.056 

Sprat 0.082 

Oil  sardines 0.118 

Sardellen 0.078 

Anchovies 0.145 

Crabs 0.020 

Oysters 0.029 

Lobster 0.022 

Eggs. 

Hen's  eggs 0 

Caviare 0 

Milk  and  Cheese. 

Milk 0 

Edam  cheese 0 

Schweitzer  cheese 0 

Limburger  cheese traces 

Tilsit  cheese 0 

Roquefort 0 

Gervais 0 

Cream  cheese 0.005 

Kuhkase 0.022 


Vegetables. 

Nitrogen  bases 
In  100  grams.  m  grams. 

Cucumber 0 

Salad 0.003 

Radishes 0.005 

Cauliflower 0.008 

Cabbage 0.007 

Chives traces 

Spinach 0.024 

White  cabbage 0 

Carrot   0 

Kale 0.002 

Curly  cabbage 0.002 

Rampion 0.011 

Kohlrabi 0.011 

Celery 0.005 

Asparagus 0.008 

Onions 0 

Green  peas 0.002 

Potatoes 0.002 

Mushrooms. 

Steinpilz 0.018 

Pfeflferlinger 0.018 

Mushrooms 0.005 

Morel 0.011 

Fruit. 

Bananas    0 

Pineapples 0 

Peaches     0 

Grapes 0 

Tomatoes 0 

Pears 0 

Plums 0 

Preisel  berries 0 

Oranges 0 

Apricots 0 

Blueberries 0 

Apples 0 

Almonds 0 

Hazelnuts 0 

Walnuts 0 

Legumes, 

Peas  (fresh) 0.027 

Peas 0.018 

Lentils 0.054 

Beans 0.017 

Cereals. 

Grits 0 

Barley 0 

Rice 0 

Tapioca 0 

Sago 0 

Oatmeal 0 

Millet 0 

Bread. 

Rolls 0 

White  bread 0 

Koumiss  bread 0 

Pumpernickel 0.003 


68  FOOD  REQUIREMENTS 

lessen  the  intake  of  purin  bases.  Normally,  on  an  unrestricted  diet,  from 
1  to  3  per  cent,  of  the  total  nitrogen  excreted  is  in  the  form  of  uric  acid. 

Various  tables  will  be  found  in  the  article  on  Gout,  and  the  table 
on  page  67,  from  Messan  and  Schmid,  is  one  of  the  latest  contributions 
on  the  subject.^  The  foods  to  be  especially  noted  on  account  of  their 
purin  content  are  printed  in  bold  type. 

The  Specific  Dynamic  Action  of  Protein. — This  may  be  briefly 
mentioned  here,  and  is  one  of  the  many  curious  and  as  yet  unexplained 
features  of  metabolism.  Each  form  of  food  excites  a  specific  ac- 
tion in  metabolism — that  is,  there  is  a  certain  amount  of  heat  or 
energy  derived  from  each  form  which  is  lost  and  not  used  by  the  body. 
Thus,  if  protein  carbohydrate  or  fat  are  fed  separately  to  cover  a 
given  requirement,  about  30  or  40  per  cent,  more  protein  would  be 
required,  about  14  to  15  per  cent,  of  fat,  and  about  6  or  7  per  cent,  of 
carbohydrate.  The  protein  raises  the  metabolism  through  some  spe- 
cific action.  On  a  mixed  diet  this  is  not  so  important.  This  effect 
of  the  food-stuffs  or  the  loss  of  energy  may  be  calculated  by  using 
factors  determined  by  Rubner.  For  protein  30.9,  fat  12.7,  and  carbo- 
hydrate 5.8.  In  a  given  diet  the  percentage  of  protein,  fat  and  carbo- 
hydrate should  be  multiplied  by  0.309,  0.127,  and  0.058  respectively 
to  determine  the  energy  percentage  lost.  Practically,  in  a  mixed  diet 
this  amounts  to  a  little  over  10  per  cent,  above  the  food  requirements 
of  starvation.  Thus,  a  man  fasting  metabolized  2400  calories,  if  a 
mixed  diet  containing  19.2  per  cent,  of  protein  is  given,  a 
total  of  2745  calories  would  be  required  to  maintain  the  indi- 
vidual. If  a  smaller  percentage  of  protein  is  given  in  the  food,  a 
somewhat  smaller  total  requirement  will  be  needed.  Rubner  advises 
a  restriction  of  proteins  in  fever  and  in  hot  weather  and  climates 
on  account  of  this  specific  dynamic  action  of  protein. 

The  Amount  of  Fat  and  Carbohydrate. — There  is  some  little  dif- 
ference of  opinion  on  this  subject.  While  it  would  not  be  well  under 
ordinary  conditions  to  omit  from  the  diet  either  all  the  carbohydrate 
or  all  the  fat,  as  a  matter  of  practical  experience  on  a  mixed  diet, 
the  exact  amount  of  fat  and  carbohydrate  does  not  make  so  very 
much  difference  as  long  as  the  total  number  of  calories  needed  to 
be  supplied  in  addition  to  that  supplied  by  the  protein  is  covered. 
Voit's  standard  was  56  grams  of  fat  and  500  of  carbohydrate.  Play- 
fair,  in  England,  reduced  the  fat  to  51,  and  increased  the  carbo- 
dydrate  to  531.  Gautier,  in  France,  suggests  65  grams  fat  and  437 
carbohydrate.  Fat  is  expensive  as  a  food,  and,  from  an  economic 
standpoint,  diets  containing  over  60  grams  are  not  apt  to  be  employed. 
In  cold  weather  the  amount  ingested  may  be  increased  if  desired, 
and  persons  doing  very  hard  physical  labor  can  take  more.  If  fat 
does  not  agree,  an  amount  of  carbohydrate  having  an  equal  caloric 
value  may  be  substituted  for  whatever  fat  is  omitted.     Fat-free  diets 

1  Therapeutisehe  monatsheft,  Berlin,  1910,  xxiv..  No.  3. 


METABOLISM  69 

are  not  advisable  either  in  infants  or  young  children.  (See  Rickets.) 
The  amount  of  carbohydrate  used  will  depend  on  the  total  number 
of  calories  needed,  and  can  be  determined  by  deducting  the  proteins 
and  fats.  A  diet  consisting  largely  of  carbohydrate  is  objectionable 
chiefl}'  on  account  of  the  bulk  and  the  strain  made  in  the  digestive 
organs. 

Mineral  Metabolism. — After  the  fundamental  facts  concerning  the 
metabolism  of  protein  of  fat  and  carbohydrate  had  been  ascertained,  it 
was  quite  natural  that  the  metabolism  of  the  mineral  elements  in 
the  food  should  come  in  for  a  large  share  of  attention.  It  is  now  pos- 
sible to  determine  the  intake  and  output  of  iron,  calcium,  magnesium, 
phosphorus,  potassium  sodium,  chlorin,  and  sulphur.  The  chief  facts 
concerning  mineral  metabolism  will  be  found  under  the  heading  of 
Salts. 

Sherman  has  suggested  as  a  standard  that  in  a  diet  containing 
2500-3500  calories  with  a  protein  content  of  75  grams  the  phosphorous 
content  should  be  1.44  grams  (about  3.5  grams  Po  0-)  the  calcium 
0.69  gram  (estimated  as  Ca  O)  and  iron  15.0  milligrams  (0.015  grams). 

DIETARIES  AND  DIETARY  STANDARDS 

Food  Economics. — The  cost  of  foods  is  most  important  and  the 
physician  should  bear  this  in  mind  in  ordering  diets  and  suit  the 
suggestions  or  orders  to  the  pocketbook  of  the  consumer.  The  United 
States  Government  is  doing  much  to  enlighten  the  people  on  the 
relation  of  food  values  to  cost,  but  the  poor  who  need  such  information 
seldom  have  it  furnished  them  or  are  too  ignorant  to  use  it.  Per- 
fectly satisfactory  diets  may  be  arranged  at  a  reasonable  cost  under 
normal  conditions,  while  high  priced  meals  may  not  be  as  suitable  or 
even  have  as  high  nutritive  value.  The  added  cost  usually,  not 
always,  brings  an  added  flavor  or  choiceness  of  food.  A  study  of  food 
values  to  the  actual  cost  should  be  made  by  anyone  having  to  cater 
to  a  family  or  institution.  In  a  general  way  local  food  products  are 
cheaper  than  those  which  have  to  be  shipped  and  non-perishable  foods 
than  the  perishable.  Vegetables  and  cereals  are  cheaper  than  meats. 
Milk,  bread  and  butter  are  also  cheap  when  one  considers  their  food 
value.  Too  much  stress  should  not  be  laid  on  the  number  of  calories, 
as  many  fresh  fuits  and  vegetables  extremely  important  in  furnishing 
bulk,  vitamins  and  salts  may  have  a  high  cost  based  on  caloric  values, 
but  not  really  be  expensive.  The  waste  in  food  should  also  be  consid- 
ered, as  many  cheap  cuts  of  meat  and  other  foods  may  have  such  a 
large  proportion  of  unavailable  material  as  to  more  than  offset  the 
difference  in  price.  What  has  been  said  under  the  subject  of  Supe- 
rior and  Inferior  Food  Proteins,  is  interesting  in  this  connection. 

Sherman  and  Gillett  (Publication  121,  New  York  Association  for 
Improving  the  Condition  of  the  Poor,  1917)  suggest  that  if  city 
dwellers  spend  an  equal  amount  for  (1)   meat,   (2)   milk,   (3)   fruit 


70 


FOOD  REQUIREMENTS 


and  vegetables,  the  result  will  result  in  a  nearer  approach  to  a  well 
balanced  dietary.  They  studied  92  families  and  the  results  are  in- 
structive.    The  following-  is  their  table : 

Aveiaye  Distribution  of  Expenditure  Among  Various  Types  of  Food  in  92  Families   (Divided 
into  4  groups  on  the  Basis  of  Cost  per  Man  per  Day). 


Cost  per   man   per  day. 
Cost  per  3000  calories  . 

Type  of  Food 


Meat-fish     

Eggs    

Milk     

Cream     

Cheese    

Pats    

Grain   products 

Sugars     

Vegetables    .  . . . 

Fruit     

Nuts    

Miscellaneous    . 

Calories    

Protein    

Phosphorus    . . . 

Calcium    

Iron     

Protein     

Phosphorus     . . 

Calcium    

Iron     


Group  I 


19.2  cents 
26.1  cents 


Per  cent. 

36.8 
4.5 
9.1 
0.3 
0.9 
6.7 

22.6 
3.4 
9.0 
2.3 
0.1 
4.3 


2043 

78  grams 
1.14  grams 
0.51  gram 
12.1  milligrams 


107  grams 
1.59  grams 
0.70  gram 
16.7  milligrams 


Groui.  II 


Group  III 


28.2  cents  34.7  cents 

30.3  cents  34.3  cents 

Percent.\ge       Distribution 

Per  cent.  Per  cent. 
29.4  34.9 

6.4  5.4 

9.2  7.8 

0.2  0.1 

1.6  0.8 

8.1  7.9 
17.7                           17.9 

4.4  3.8 

9.0  9.2 

7.2  6.4 
0.6  0.1 
6.2                             5.7 

Food  Value  pek  Mati  pee  Day 


2665 

91  grams 
1.39  grams 
0.64  gram 
14.9  milligrams 


3106 

109  grams 
1.60  grams 
0.72  gram 
17.7  milligrams 


Food  Value  pee  3()00  Calories 
104  grams  I    102  grams 

1.57  grams  1.54  grams 

0.77  gram  0.71  gram 

16.7  milligrams  I    17.1  milligrams 


Group  IV 


49.4  cents 
44.7  cents 


Per  cent. 
31.8 

5.9 

8.4 

1.2 

1.2 

9.8 
13.1 

3.6 

9.3 

8.2 

0.6 

6.9 


3889 

126  grams 
1.95  grams 
'.01  grams 
20.6  milligrams 


116  grams 
1.69  grams 
0.81  gram 
17.9  milligrams 


' '  It  is  clearly  evident  that  the  average  expenditure  in  Group  I  was 
too  low  to  provide  sufficient  energy  for  that  group.  If,  however,  the 
cost  and  food  factors  for  each  group  be  recalculated  in  proportion  to 
3,000  calories  we  have  a  basis  for  comparison  which  indicates:  (1) 
that  if  energy  be  sufficient  the  other  food  factors  will  on  the  average 
be  adequately  supplied,  and  (2)  that  Group  I  was  getting  practically 
the  same  amount  of  food  value  for  26  cents  for  which  Group  IV  was 
paying  45  cents.  It  should  also  be  noted  that  while  only  one-fourth 
were  spending  for  food  less  than  25  cents  per  man  per  day,  about  50 
to  75  per  cent,  were  not  getting  enough  energy." 

The  proportion  of  the  income  to  be  spent  in  food  has  been  studied 
by  the  Russell  Sage  Foundation,  and  they  suggest  the  following  for  a 
family  of  mother,  father  and  three  children: 

Proportion  of  Income  to  Be  Spent  for  Food. 


Amount  per  day 

Amount 

Income 

Percentage  for 

Total  for  food 

for  family  of 

per  day 

per  year. 

food  per  year. 

])er  year. 

five. 

per  person 

$  500 

55.0 

$275 

$0.75 

0.15 

800 

45.6 

365 

1.00 

.20 

1000 

45.0 

450 

1.20 

.24 

1100 

45.0 

490 

1.34 

.27 

1200 

44.6 

540 

1.48 

.29-1- 

1500 

36.8 

552 

1.50 

.30 

2000 

30.0 

600 

1.64 

.33 

METABOLISM  71 

Planning  Diets. — A  perfectly  balanced  ration  is  one  which  takes 
into  consideration  the  following  factors.  Our  ideas  of  the  complete- 
ness of  a  diet  are  constantly  changing-  as  the  study  of  nutrition  is 
making  clear  many  little  understood  points.  The  easiest  way  to  work 
out  a  dietary  is  to  determine  according  to  the  data  already  given  the 
number  of  calories  required.  Of  this  amount  from  10  to  15  per  cent, 
(from  60  to  120  grams  for  an  adult)  should  be  furnished  by  protein. 
Sedentary  and  indoor  people  require  less  than  active  outdoor  ones. 
The  nature  of  the  proteins  should  be  considered  and  those  containing 
the  requisite  amounts  of  the  necessary  amino-acids  should  be  included. 
The  relative  value  of  some  of  the  proteins  are  given  under  the  para- 
graph on  Superior  and  Inferior  Proteins.  The  proteins  found  in  milk 
and  meat  are  more  valuable  than  the  ones  in  vegetables.  The  re- 
mainder of  the  calories  are  to  be  made  up  in  fat  and  carbohydrate. 
These  are  interchangeable  within  certain  limits.  It  has  been  stated 
that  on  a  basis  of  caloric  values  the  proportion  of  fats  to  carbohydrates 
may  varj'  as  widely  as  7  to  2.  In  cold  weather  and  climates  and  in 
hard  work  the  fat  may  be  increased.  As  a  matter  of  fact  fat  is  ex- 
pensive so  that  the  amounts  taken  in  are  small,  as  a  rule,  25  to  75 
grams  a  day,  and  the  balance  in  carbohydrates.  In  hot  weather  and 
climates  and  for  sedentary  people  carbohydrates  are  used  in  larger 
proportions. 

The  diet  must  also  contain  a  full  amount  of  the  various  salts  needed 
in  metabolism  and  on  a  generous  mixed  diet  this  will  always  be  the 
case,  but  on  a  restricted  diet  the  salts  may  be  so  low  as  to  interfere 
with  nutrition.  The  only  mineral  constituents  that  have  been  suffi- 
ciently studied  to  know  about  the  requirements  are  iron  0.015  gm. 
daily,  calcium  CaO,  0.70  gm.  daily  and  phosphorus  P2  O5  2.75  gm. 
average  daily.  Iron  containing  foods  of  great  value  are  spinach, 
lettuce,  asparagus,  and  similar  things,  the  legumes,  yolk  of  egg  and 
meat.  Calcium  containing  foods  of  greatest  value  are  milk,  cheese, 
cauliflower,  string  beans,  carrots,  lettuce,  rhubarb,  oranges  and 
lemons.  The  phosphorus  containing  foods  of  greatest  value  are 
skimmed  milk,  milk,  cheese,  legumes,  meat,  yolk  of  egg,  oatmeal,  cauli- 
flower, spinach,  lettuce,  asparagus,  green  peas  and  beans,  and  toma- 
toes. With  ordinary  diets  the  requirements  are  easily  met  and  this 
emphasizes  the  importance  of  milk,  fruits,  salads,  and  other  green 
vegetables.  It  is  also  important  that  the  foods  furnish  more  bases 
than  acids  (see  Alkalis  and  Acids),  and  meats,  cereals,  and  other  acid 
forming  foods  should  be  offset  by  those  containing  alimentary  alkalis, 
as  potatoes,  bananas,  and  other  vegetables  and  fruits. 

Certain  important  substances  occur  in  animal  fats  which  should 
always  form  a  part  of  the  diet,  such  as  fat  from  meats,  butter  and 
cream.  Vitamins  are  also  important  and  seem  to  bear  a  relation  to 
the  phosphorous  content  of  the  food  and  diets  low  in  phosphorous 
should  have  their  content  increased  by  fresh  or  dried   (not  canned) 


72  FOOD  REQUIREMENTS 

legumes,  the  whole  grains  of  cereals,  etc.  (See  Vitamins).  There 
should  always  be  an  anti-scorbutic  in  the  diet,  such  as  some  fresh 
fruit  or  vegetable.  The  increased  use  of  sterilized  canned  foods 
makes  this  imperative.  The  food  should  be  such  as  contains  sufficient 
bulk.  Among  the  well-to-do,  as  a  rule,  the  ordinary  daily  diet  natu- 
rally includes  all  the  necessaries,  but  among  the  poor  and  ignorant 
and  in  institutions  and  where  large  numbers  of  persons  are  fed  to- 
gether, grave  errors  of  diet  may  lead  to  serious  diseased  conditions. 
(See  also  Basic  Quantity  Food  Tables.) 

Vitamins. — Of  recent  years  it  has  become  evident  from  nutrition 
experiments  that  growth  and  life  is  more  than  supplying  the  animal 
body  with  certain  amounts  of  protein,  carbohydrate,  and  fats.  It 
has  been  made  very  plain  that  the  character  of  these  as  elementary 
substances  is  very  important  and  that  certain  substances  are  present 
in  certain  foods  and  are  absent  in  others,  and  that  these  substances, 
which  Funk  has  proposed  to  call  vitamins,  are  essential  to  life  and 
growth.  The  exact  nature  of  these  vitamins  has  not  been  determined 
and  there  is,  just  at  the  present  time  (1917),  much  discussion  con- 
cerning them,  with  which  it  is  not  necessary  to  concern  ourselves  at 
the  present.  Animals  of  various  kinds  have  been  fed  on  special  diets, 
ample  to  cover  all  the  needs  in  the  way  of  protein,  carbohydrate  and 
fat,  but  not  foods  containing  vitamins.  Young  animals  grow  for  a 
certain  time  and  then  come  to  a  standstill  and  eventually  sicken  and 
die  unless  some  of  the  vitamin  containing  foods  are  added.  Butter-fat 
and  cod  liver  oil  contain  these  substances,  while  olive  oil  does  not. 
They  are  found  in  milk  and  eggs,  in  orange  juice  and  other  fresh 
fruit  juices,  and  in  the  bran  or  pericarp  of  wheat  and  rice  and  other 
cereals.  Vitamins  of  one  kind  or  another  seem  to  be  intimatelj^  con- 
nected with  the  production  of  scurvy,  of  pellagra,  of  beri-beri,  and 
probably  of  other  diseases.  Vitamins  are  also  essential  to  the 
growth  of  young  animals  and  without  them  animals  fail  to  reach 
mature  growth  and  eventually  sicken  and  die  from  metabolism. 

Carrel  found  that  in  growing  animal  tissues  outside  tlie  body 
in  adult  blood  serum  the  tissues  would  live  a  long  while,  but  would 
not  grow,  but  that  if  placed  in  blood  serum  from  the  young  and  grow- 
ing that  the  tissues  began  to  grow,  showing  that  there  are  substances 
in  the  tissues  of  the  young  necessary  for  growth  riot  found  in  the 
mature  animal. 

McCollum,  Simmonds  and  Pitz  believe  that  there  are  soluble  sub- 
stances in  those  fats  which  are  of  especial  importance  in  growth. 
They  suggest  the  term  fat  soluble  A  and  water  soluble  B.  Butter 
fat  and  egg  yolk  apparentlj^  contain  more  of  these  substances  than 
other  natural  foods,  but  some  is  found  in  animal  tissues,  especially  in 
the  active  organs.  They  are  also  present  in  small,  but  inadequate 
amounts  in  the  cereal  grains  and  in  larger  amounts  in  the  leaves  of 


METABOLISM  73 

the  forage  plants.  The  vegetable  oils  contain  very  little,  if  any. 
These  substances  are  also  found  in  certain  seeds,  such  as  corn  kernel. 
Extracts  which  contain  water  soluble  B  will  relieve  the  polyneuritis 
in  pigeons  induced  by  diets  of  polished  rice  or  purified  foodstuffs. 
(American  Journal  of  Physiology,  Sept.,  1916,  pp.  333  and  361.) 

Acids  and  Alkalis. — The  question  of  acids  in  base-forming  prop- 
erties of  food  is  extremely  important  and  is  being  studied  to  advantage 
(see  also  Acidosis  and  Mineral  Salts).  There  is  still  a  great  deal  of 
confusion  as  regards  the  composition  of  the  various  food  materials,  the 
older  studies  taking  into  account  either  the  whole  plant  or  the 
product. and  were  made  by  agricultural  chemists  whose  chief  interest 
was  in  what  was  taken  out  of  the  soil.  The  newer  studies  have  dealt 
with  the  composition  either  of  the  food  as  purchased  or  of  the  edible 
portion  or  as  prepared  for  the  table  and,  in  many  instances,  the  tables 
did  not  show  which  particular  preparation  of  food  was  analyzed. 
This  is,  however,  being  rapidly  corrected.  In  this  connection  the  work 
of  Sherman  and  Gettler  ( Journal  of  Biological  Chemistry,  1912,  xi, 
p.  323)  and  Sherman  (Food  Products)  is  of  great  interest,  the 
latter  work  containing  full  tables  showing  the  content  based  on  hun- 
dred calorie  portions.  This  basis  is  rather  better  for  practical  use 
than  a  hundred  gram  basis,  iimsmuch  as  differences  in  the  water  con- 
tent in  the  latter  yield  dift'erences  in  the  figures.  By  estimating  the 
diff'erence  between  the  acid  ash  and  the  basic  ash  of  the  foods  it  may 
be  determined  whether  they  will  increase  the  acidity  of  the  body  or 
decrease  it.  Foods  furnishing  acids  are  chiefly  meats,  eggs,  grain 
products,  particularly  the  whole  grains,  and  peanuts.  Plums,  prunes, 
and  cranberries,  although  yielding  a  basic  ash,  increase  the  acid  for- 
mation owing  to  the  benzoic  acid  content.  Milk  is  regarded  as  either 
neutral  or  slightly  basic,  while  most  of  the  alkalis  are  furnished  by 
fruits  and  vegetables  and,  as  Blatherwick  has  shown,  potatoes,  oranges, 
raisins,  apples,  bananas  and  lettuce  are  very  useful  in  reducing  the 
acid  output.     Tomatoes  are  of  less  value. 

The  actual  computations  are  scarcely  ever  made  outside  of  very 
careful  dietetic  studies,  but  when  it  is  thought  advisable  to  increase 
the  bases  taken  in  a  food,  those  foods  are  added  to  the  dietary. 
In  any  well  balanced  ration  the  proportion  of  alkali  furnishing  foods 
should  balance  the  ones  furnishing  acids.  Sherman  suggests  comput- 
ing this  then  in  terms  of  normal  solutions  and  that  it  is  preferable 
to  have  the  balance  on  the  basic  side  and  that  an  excessive  acid-form- 
ing element  be  permitted.  It  would  seem  that  the  excess  should  not 
exceed  25  units  of  the  equilibrium  of  the  man  per  day,  which  is 
about  the  quantity  neutralizable  by  the  amount  of  ammonia  to  be 
expected  in  a  day's  urine  under  favorable  conditions.  The  following 
table  from  Sherman  and  Gettler  shows  the  acid  or  base  excess  value  of 
the  foods  most  commonly  used : 


74 


FOOD  REQUIREMENTS 


Excess  of  Acid-Forming  or  Base-Forming  Elements. 


Article  of  Food. 


Excess  Acid  or  Base  in  Terms  of  Normal  Solutions. 


Per  100  grams. 


Acid, 
c.c. 


Base, 
c.c. 


Per  100  calories. 


Acid, 
c.c. 


Base, 
c.c. 


Almonds     

Almonds    

Apples    

Asparagus   

Bananas     

Beans,  dried 

Beans,  dried   

Beans,  lima,  dried  . 

Beets    

Cabbage  

Cabbage   

Carrots    

Cauliflower    

Celery     

Cherry  juice 

Chestnuts    

Corn,  sweet,  dried  . 

Crackers    

Currants,  dried    .  .  . 

Eel    

Eggs  

Egg  white 

Egg  yolk   

Fish,  haddock 

Fish,  pike 

Lemons    

Lettuce     

Meat,  beef,  lean.  I 
Meat,  beef,  lean,  II 
Meat,  beef,  lean  .  . 
Meat,  beef,  lean   .  .  . 

Meat,  chicken 

Meat,  frog 

Meat,  pork,  lean   . 

Meat,  rabbit 

Meat,  veal 

Meat,   venison    ... 

Milk,  cow's   

Milk,  cow's 

Muskmelon    

Oatmeal     

Oatmeal     

Oranges    

Peaches    

Peanuts    

Peas,  dried   

Peas,  dried   

Potatoes,  I    

Potatoes,  II    

Potatoes     

Prunes    

Prunes   

Radishes    

Raisins     

Raspberry  juice   .  . 


5.95 

7.81 

9.89 
11.10 

5.24 
26.69 
16.07 
11.81 


13.91 
10.50 
12.00 
13.67 
17.01 
10.36 
11.87 
14.80 
13.52 
15.83 


12.93 
10.63 


3.9 


12.38 

11.76 

3.76 

0.81 

5.56 

23.87 

11.58 

41.65 

10.86 

4.34 

7.10 

10.82 

5.33 

7.78 

4.40 

7.42 


5.97 
7.55 


5.45 
7.37 


2.37 
1.26 

7.47 


5.61 
5.04 

7.07 

3.36 

7.19 

5.5 

7.72 

24.40 

25.55 

2.87 

23.68 

4.91 


1.77 
1.95 


9.52 

7.08 


12.10 

8.74 
10.44 
11.89 


3.23 
2.66 


0.70 


1.86 

1.76 

5.98 

3.65 

5.62 

6.92 

3.36 

12.08 

23.57 

13.76 

22.51 

23.91 

17.48 

42.17 

3.19 


1.85 


12.32 
38.69 


3.44 
1.83 

18.82 


10.94 
12.20 

1.98 
0.94 
8.63 

9.26 
8.05 

8.43 
9.79 
6.87 


METABOLISM 


75 


Excess  Acid  or  Base  in  Terms  of  Normal  .Solutious. 

Article  of  Food. 

Per  100  grams. 

Per  100  calories. 

Acid, 
c.c. 

Base, 
c.c. 

Acid, 
c.c. 

Base, 
c.c. 

Rice,  I    

Rice,  II    

Rice       

8.1 

7.08 

8.35 

9.66 
12.39 
11.61 

2.68 
6.80 

3.35 
2.05 
2.42 

3.25 
3.47 
2.70 

Turnips    

Turnips    

Wheat,    entire    

Wheat,    entire    

Wheat,  flour   

6.86 
9.41 

The  Calculation  of  Rations. — Numerous  suggestions,  tables  and 
devices  have  been  offered.  In  armj'  and  navy  life  and  in  ordering 
food  for  large  numbers  of  people  certain  standards  are  used,  con- 
structed more  with  the  view  of  satisfying  the  appetite  than  any 
theory  of  metabolism.  Practically  they  work  out  about  as  above,  and 
usually  contain  about  100  to  125  grams  protein,  50  to  65  grams  fat, 
and  the  balance  up  to  about  3500  calories  or  more  in  carbohydrate. 
The  tables  of  foods  ordinarily  used  are  arranged  so  at  a  glance  the 
amount  needed  for  any  number  of  "rations"  or  people  may  be  told. 
In  the  army  conversion  tables  these  figures  show  the  amount  needed 
for  one  and  any  number  up  to  100,000.  For  the  purveying  of  food 
such  tables  are  of  great  help.  Tables  showing  the  comparative  cost 
of  foods  and  their  full  value  are  of  use  in  supplying  a  nutritious  diet 
on  as  cheap  a  basis  as  possible.  This  economic  side  of  diet  is  of  the 
greatest  importance,  and  one  well  worthy  of  the  study  of  physicians 
and  laymen.     (See  also  Basic  Quantity  Food  Tables.) 

A  Food  Scale. — Hart  has  devised  a  food  scale  which  makes  it 
comparatively  easy  for  the  patient  to  weigh  his  food  for  himself,  a 
very  important  factor  for  the  treatment  of  patients  who  are  on  strictly 
regulated  diets.  The  majority  of  these  patients  cannot  afford  nor  will 
they  tolerate  the  presence  of  a  trained  attendant  and  most  of  them 
are  not  sufficiently  ill  to  be  in  a  hospital.  Hart  gives  the  following 
description  of  his  scale :  ' '  This  is  an  accurate  spring  scale  of  modest 
dimensions,  6  inches  high  and  with  a  5  inch  base,  finished  in  nickel 
and,  therefore,  not  too  conspicuous  to  be  used  at  the  table.  It  is  fitted 
with  a  broad  circular  plate  which  easily  supports  the  dish  on  which 
the  food  is  weighed  and  it  has  a  base  sufficiently  wide  to  keep  the 
scale  from  being  easily  upset.  The  scale  is  made  to  indicate  grams, 
having  a  total  capacity  of  1000  grams,  the  dial  being  figured  for 
every  100  grams,  with  subdivisions  indicating  20  grams  each.  By  a 
special  contrivance  the  dial  can  be  quickly  rotated  to  any  desired 
point,  by  means  of  a  small  knob.  The  result  is  that  the  zero  point 
can  be  brought  easily  to  any  position  desired. 

"The  method  of  using  the  scale  is  as  follows:  Suppose  the  food 
prescription  for  a  given  meal  consists  of 


76 


FOOD  REQUIREMENTS 


Meat 
Potatoes 
String  beans 
Wheat  bread 


100  grams 
80  grams 

120  grams 
60  grams 


Fig.  1. — A  food  scale  with  an  adjustable  dial. 

*  *  An  empty  plate  is  placed  on  the  scale  and  by  means  of  the  knob  the 
dial  is  rotated  until  the  zero  point  is  opposite  the  end  of  the  pointer; 
meat  is  placed  on  the  plate  until  the  pointer  indicates  100.  grams ;  the 
dial  i-s  again  rotated  until  zero  is  opposite  the  pointer ;  potato  is  added 
until  80  grams  are  indicated,  and  so  on,  the  zero  point  on  the  dial  each 
time  brought  opposite  the  pointer  until  at  the  completion  of  the 
operation  we  have  on  the  plate  all  the  food  for  the  meal,  each  kind  of 
food  accurately  weighed."  (Jour.  Am.  Med.  Assn.,  August  7,  1909, 
liii,  457.) 

After  two  or  three  weeks  the  patient  can  learn  to  judge  by  the  eye 
the  size  of  a  piece  of  meat  or  bread  or  other  food  which  he  is  allowed 
and  in  some  instances  the  use  of  the  scales  can  be  done  away  with 
after  this  has  been  thoroughly  mastered. 

The  Prescribing  of  Diets. — The  physician  usually  deals  with  the 
individual  and  the  individual  diet,  and  there  is  a  growing  demand 
for  the  scientific  supervision  of  diet  in  health  and  in  disease.  Many 
physicians  get  hopelessly  entangled,  and  finally  fall  back  on  set  diet 
lists.  To  be  able  to  understand  the  prescribing  of  food  one  must  know 
certain  facts  and  figures  and  be  familiar  with  the  values  of  simple  foods 
in  the  amounts  usually  eaten.  The  number  of  calories  furnished  by 
the  protein,  fats,  and  carbohydrates  in  any  given  food  must  also  be 
known,  so  that  diet  may  be  varied  to  suit  the  individual  need.  Facility 
in  this  may  be  acquired  easily  by  calculating  from  the  tables  given 
below  the  food  actually  eaten  by  the  physician  himself.  The  weighing 
of  the  amounts  served  is  the  most  accurate,  but  after  a  few  times  the 
amount  may  be  judged  by  the  eye.     The  totals  will  always  be  only 


PLANNING  DIETS 


77 


approximate,  but  sufficiently  accurate  for  the  purposes  of  medical 
practice.  The  terms  "a  moderate  helpiiiu,"  etc.,  mean  little  unless  the 
portions  have  been  checked  up  by  actual  weighing-. 

The  following  facts  must  be  learned,  and  should  be  copied  on  a 
card  and  carried  about  until  they  are  memorized : 

1  gram  protein  =  4.1  or  4  calories] 

1  gram  fat  =  9.3  or  9  calories  \  approximately. 

1  gram  carbohydrate  =  4.1  or  4  calories  J 

1  gram  alcohol  =  7. 

^' ::'''''''' C^L.  i'or  n,an  05  kilos  or  154  pounds. 

Per  pound.  Per  kilo.  Total  calories. 

Rest  in  bed 14                 28  1800 

Repose   Hi                  32  2100 

Light   work    17                  33  2300 

Moderate  work    20                 40  2000 

Hard  work   24                 48  3100 

The  protein  requirement  is  approximately  1  to  2  grams  per  kilo  or 
^{>  to  1  gram  per  pound  of  body  weight,  giving  an  average  of  from 
60  to  120  grams  for  a  man  of  65  kilos  or  154  pounds.  These  are  the 
minimum  and  maximum  under  ordinary  conditions.  In  actual  diet- 
ing, unless  especial  care  is  taken,  the  protein  will  increase  with  the 
increase  in  calories  on  a  general  mixed  diet.  If  the  individual  is  doing 
hard  work  and  is  in  good  health,  this  does  not  apparently  affect  the 
general  well  being.  If  the  caloric  value  of  a  food  per  pound  is  known, 
dividing  by  4.5  will  give  the  approximate  number  of  calories  per  100 
grams ;  or  if  the  value  per  hundred  grams  is  known  multiplying  this 
by  4.5  will  give  the  caloric  value  per  pound. 

To  compute  easily  the  number  of  calories  in  a  diet,  or  to  prescribe 
it,  several  methods  have  been  suggested.  Wilson  and  Rathburn  (Jour- 
nal American  Med.  Assn.  June  3.  1916,  1760,)  give  the  following 
scheme  to  help  in  computing  the  calories  in  a  dietary.     Irving  Fisher 


Number    of 
pounds    of 
protein 
consumed 

-1- 

Xumber  of 
pounds  of 
carbohydrate 
consumed 

X  1.820  - 

Total  calories 
of   protein    and 
carbohydrate 
consumed 

+ 

Numtjer    of    pounds 
of    fat    consumed 

X  4.080  = 

Total    calories    of 
fat    consumed 

II 

Average 
number    of 
calories 
per  capita 

-^ 

Number  of 
l)ersons    served 

= 

Total  calon 

es  for  da.v 

per   diem 

Diagrammatic  scheme  for  computing  the  caloric  content  of  a  dietary.     Pounds 
are  converted  into  grams  by  multiplying  by  453..'592.5  or  roughly  454. 

has  compiled  the  table  given  below,  showing  the  amounts  of  foods  in 
common  use  necessary  to  equal  100  calories ;  by  combining  the  amounts 


<0  FOOD  REQLIREMEXTS 

the  total  number  of  calories  can  easily  be  obtained.  This  is  a  simple 
method  of  prescribing  diets,  but  less  useful  in  determining  the  value  of 
a  given  diet,  unless  it  has  been  served  in  standard  portions  or  fractions 
of  such  portions.  This  method  is  admirably  suited  where  there  is  some 
one  to  superintend  the  serving,  as  in  sanitariums,  in  hospitals  where 
the  food  is  served  from  a  diet  kitchen,  and  in  private  homes  where 
there  is  a  trained  nurse.  The  patient  or  nurse  writes  down  the  name 
of  the  article  and  the  amount  of  protein  eaten,  and  by  using  the  table 
the  food  value  is  easily  ascertained,  as  follows : 

Protein.  Fat.  Carbohydrate. 

1  portion  boiled  fat  beef 40  60 

1       ■'          baked   potato    11  1             88 

1       "          corn     13  10             77 

1       "          bread    13  6             81 

1       "          apple     3  7             90 

Total  calories,  500 90  8-i  336 

With  this  Fisher  has  arranged  a  graphic  method  of  representing 
these  values,  full  details  of  which  will  be  found  in  the  Journal  of  the 
American  ]\Iedical  Association,  vol.  xlvii..  No.  20,  November  7,  1906. 

Tracy  (New  York  Medical  Journal,  Jan.  13,  1917.  75.)  has  con- 
structed a  plan  and  some  tables  based  on  Locke's  tables  which  makes 
the  selection  of  a  balanced  ration  a  comparatively  easy  matter  and 
avoids  the  necessity  of  computing.  The  protein  content  of  these  diets 
is  very  low  and  the  meat  portions  might  well  be  increased  except  for 
the  sedentary.     Tracy 's  method  is  as  follows : 

Bearing  in  mind  the  two  main  requirements  for  the  daily  diet, 
namely,  that  it  shall  contain  approximately  65  grams  of  protein  with 
2,500  total  calories,  or  75  grams  of  protein  with  3,000  total  calories, 
these  tables  have  been  made  to  include  only  data  as  to  the  weight  of 
protein  and  the  total  fuel  value  of  the  foodstutK:.  Since  multitudes  of 
figures  are  in  themselves  a  bewilderment  to  one  unaccustomed  to  their 
use,  it  is  believed  advisable  to  eliminate  as  many  unessential  figures 
as  possible. 

In  tables  as  brief  as  these,  undoubtedly  there  will  frequently  be 
noted  the  omission  of  a  vegetable  or  a  dessert,  or  other  food  article 
which  is  desired  for  a  particular  menu,  but  by  reference  to  the  Locke 
or  Gephart  tables  such  an  article  can  be  looked  up  as  occasion  demands 
and  added  in  its  proper  place  according  to  the  amount  of  protein  and 
total  fuel  value.  Thus,  according  to  the  family  tastes,  the  tables  may 
be  enlarged  from  time  to  time. 

In  order  to  bring  together  portions  which  are  comparatively  uniform 
as  regards  protein  or  fuel  content,  the  portion  as  described  by  Locke 
is  in  some  instances  modified  by  a  qualifying  word,  large  or  small,  and 
the  analytical  figures  changed  by  a  corresponding  definite  percentage 
increase  or  decrease.  Wherever  this  has  been  done  the  sign  ( t )  is 
placed  before  the  name  of  the  article.     Thus  the  quantities  suggested 


PLANNING  DIETS 


79 


for  a  portion  are  approximate  only,  but,  it  is  believed,  are  sufficiently 
uniform  to  constitute  a  basis  for  every  day  planning  of  the  household 
meals.  A  little  larger  portion  on  one  day  will  undoubtedly  be  bal- 
anced by  a  smaller  portion  on  another  day,  and  great  accuracy  is  not 
necessary.  A  weekly  ration  of  17,500  calories  is  without  doubt  quite 
as  satisfactory  as  a  daily  ration  of  2,500  calories  for  seven  days. 

In  using  these  tables  the  following  simple  rules  will  readily  lead  to 
the  combinations  of  food  materials  which  will  supply  the  nutritive 
requirements  and  add  the  desirable  variety  to  the  daily  menus. 

1.  For  the  heaviest  meal  of  the  day — dinner — select  one  article 
from  each  of  Tables  I,  II,  and  III. 

2.  For  luncheon,  or  supper,  select  one  article  from  each  of  Tables 
II,  III,  and  IV. 

3.  For  breakfast  select  one  article  from  each  of  Tables  III,  IV, 
and  V. 

•4.  Add  together  the  protein  values  and  determine  what  addition 
of  protein  is  needed  to  complete  the  daily  requirement. 

5.  Add  together  the  total  calorific  values,  and  to  this  total  add 
600  calories,  which  will  be  incidentally  taken  during  the  day  in 
accessories,  as  sugar,  cream,  butter,  sauces,  etc.  (Table  IX.)  De- 
termine what  fuel  value  must  be  added  to  bring  the  total  for  the  day 
up  to  the  requirement. 


Table  I. 

Meats,  Poultry,  Fish,     f — modification  of  Locke's  "portion." 
Higli  Protein  Foods. — Only  one  article  from  this  table  should  be  served  at  a 
meal,  and  preferably  only  once  a  day. 


Food  Article. 
Section  A 


Portion 


fBeef,  roast 1   small  slice   .  . 

Beef,  steak   1  slice 

tChicken,  fricassee large  helping  .  . 

tLamb,  roast li^  slices   

Lamb,  chops 1  average  chop  . 

tMutton,  roast 3  slices   

tHam,  boiled   large  slice 

fTurkey,  roast small  slice   .  .  .  . 

tSalmon    large  helping  .  . 

fMackerel  double  helping  . 

Section   B 

Beef,  scraped  (round)    .4  in.  pat 

tChicken,  roast   small  helping  .  . 

Mutton,  chops 1  chop 

Mutton,  boiled 1  slice 

fPork,  roast small  slice   .  . . . 

fPork,  chops    1  large  chop  .  . . 

Veal,  roast  1  slice 

fBluefish small  helping  .  . 

Codfish    average  helping 

Halibut  average  helping 

Spanish  mackerel   average  helping 

tClams  (long)    10  clams 

tCrab,  hard  shell 1  large  crab  .  . . 


Protein 
Grams. 


Rough 
average 
21  grms. 


Total 
Calories. 


Rough 
average 
265  cals. 


Rough 
average 
130  cals. 


80 


FOOD  REQUIREMENTS 


6.  Supplement  the  protein  and  fuel  as  may  be  indicated  by  the 
necessary  additions,  according  to  taste,  and  to  any  meal  desired,  of 
articles  from  one  or  more  of  Tables  IV  to  VIII. 

7.  Do  not  let  the  daily  protein  run  above  75  grams  for  any  length 
of  time.  The  total  fuel  value  of  the  food  may  run  above  2500  or 
3000  calories  without  harm,  especially  in  cold  weather,  unless  one 
tends  to  become  excessively  fat. 

8.  Remember  that  the  total  fuel  value  of  the  ration  must  be  in- 
creased if  very  active  or  severe  muscular  work  is  to  be  done,  and 
see  to  it  that  such  active  worker  receives  double  or  triple  portions  of 
the  food  articles  provided. 

9.  After  the  occasional  feast  day,  which  will  do  no  harm  to  a 
vigorous  digestive  tract,  eat  a  little  less  for  a  day  or  two  until  the 
weekly  balance  is  struck. 

By  such  use  of  the  tables  a  general  appreciation  of  the  nutritive 
value  of  the  common  foodstuifs  will  be  acquired  in  a  remarkably 


Table  II. 

Green  Vegetables. — Low  fuel  and  protein  value  (exception,  corn).  Valuable  for 
salts,  vitamines,  and  bulk.  At  least  one  article  from  this  table  should  be  included 
in  the  day's  ration. 


Food  Article.  Portion 

Squash    2  heap,  tablesps. 

Spinach     2  heap,  tablesps. 

Tomatoes,  raw 1  average  size    . 

Tomatoes,  cooked   3  heap,  tablesps. 

Asparagus,  canned average  helping 

Beets  2  heap,  tablesps. 

String  beans   3  heap,  tablesps. 

Carrots  3  heap,  tablesps. 

Cabbage 3  heap,  tablesps. 

Cauliflower    2  heap,  tablesps. 

Turnips 2  heap,  tablesps. 

Corn,  green  boiled 1   ear     


Protein 

Total 

Grams. 

Calories. 

1.3 

Rough 

2.1 

^      average 

2.4 

55  cals. 

1.2 

1.8 

Rough 

1.6 

i-      average 

0.7 

20  cals. 

0.5 

0.6 

Rough 

1.0 

average 

0.4 

7  cals. 

3.5         J 

140  cals. 

Any  of  the  above  articles  used  as  salad  with  mayonnaise  dressing  will  be. in- 
creased in  fuel  value  by  187  calories. 

Cream  sauce  added  in  serving  any  of  the  above  articles  will  increase  the  fuel 
value  by  91  calories. 

Table  III. 

'■Starchy"  vegetable  foods.     High  fuel  value   (carbohydrate). 

Low  Protein. — Only  one  article  from  this  table  should  be  used  at  a  meal. 


Food  Article. 


Portion 


Potatoes — white    

Baked    1   medium  size    .  . 

Boiled    1  medium  size    .  . 

Creamed    4  heap,  tablesps. .  . 

tMashed   •  •  ■  3  heap,  tablesps. .  . 

Potatoes — sweet  boiled  .  1  small  size 

fRice,  boiled IVo  heap,  tablesps. 

Macaroni,  boiled 3  heap,  tablesps. .  . 


Protein 
Grams. 


Rough 
average 
3.5  grms. 


Total 
Calories. 


Rough 
average 
140  cals. 


PLANNING  DIETS 


81 


short  time,  and  the  housewife  in  planning  the  meals  for  the  day,  or 
the  individual  selecting  his  or  her  own  food  in  a  restaurant,  will  by 
second  nature,  or  with  an  educated  common  sense,  tind  no  difficulty 
in  meeting  the  nutritive  requirements  without  special  thought  as 
to  protein  or  calories. 

Tablk  IV. 

Foods  containing  moderate  protein  of  animal  origin. 

Two  articles  from  this  table  may  be  used  at  the  same  meal,  but  preferably  not 
with   articles   from  Table  I. 


Food  Article. 
Section   A 


Portion 


Protein 
Grams. 


Egg,  boiled 

Egg,  raw    

Milk,  skimmed  .  .    . 
Buttermilk     (from 

churn )    

American  cheese  .  . 

Cream  cheese 

Chicken  sandwich   . 

Ham,  fried 

Sardines,  canned  .  . 

Oysters,   raw    

Whole  milk    

Omelette,  3  eggs   .  . 


1  f^SS  ■ 
1   egg  . 

1  glass 


Meat  stew 

Custard  pudding 
Sausage,   country 

Bacon    

Ham   sandwich    . 
Cream  toast  .... 


.  1  glass    

.  1  cu.  in 

.  1  cu.  in 

.  1  sandwich 

.  average  portion 

.  3  fish 

.  1)   oysters    

.  1  glass 

.  Vg  omelette 

3  tablesps.  milk   . .  .  . 

1  heap,  teasp.  butter 

.  average  helping 

.  2  heap,  tablesps 

.  1  large  sausage 

.  2  slices   

.  1  sandwich 

.  2  slices  with  a 

tablesps.  sauce  . .  .  . 


Macaroni,     baked     with 

cheese    

tCustard  pie    

Mince  pie    

Section  B. — Foods  containing  moderate  protein  of  vegetable  origin.  Two  arti- 
cles from  this  table  may  be  used  at  the  same  meal.  Useful  with  or  without  arti- 
cles from  Table  I  to  raise  the  protein  ration  up  to  the  requirement. 


I  tablesp 
1/5  pie  .  .  . 
Vg  pie  . .  . 


Eough 
average 
7.2  grms. 


Total 
Calories. 


Rough 
average 
80  cals. 


Rough 
average 
150  cals. 


Rough 
average 
300  cals. 


Food  Article. 


Portion 


Baked  beans,  canned   .  .  3  heap,  tablesps. 

Lima  beans 2  heap  tablesps. 

Green  peas 4  heap,  tablesps. 

tPeanuts 20  nuts 

tBrazil   nuts    7  large  nuts  .... 

tPecans 20  large  nuts  .  .  . 

Walnuts    10  nuts 

Cocoa 1  cup 

1  heap,  teasp.  cocoa  . 
1  heap,  teasp.  sugar 

%  cup  milk 

1  tablesp.  cream   .... 


Protein 
Grams. 


Rough 
average 
7.2  grms. 


Total 
Calories. 

Rough 
average 
140  cals. 


Rough 
average 
300  cals. 


82 


FOOD  REQUIREMENTS 


Table  V. 

Breadstuff s  and  Cereals — High  fuel  value  (carbohydrate)   with  low  protein. 

Section  A — Breadstuffs.     Useful   additions  to   every  meal  in  twice  and  three 
times  the  portion  given. 


Food  Article. 


Portion 


Corn  bread Slice  3  x  2  x  %  in.  ... 

White  bread,  baker's  .  .  .  Slice  3i^  x  3  x  Vo  in.  . 

White  bread,  homemade.  Slice  3  x  4  x  %  in.  ... 

Vienna  roll 1  roll    

Biscuit,  homemade  ....  I  biscuit 

Graham  bread Slice  3%  x  2%  x  %  in. 

Whole  wheat  bread  ....  Average  slice 

tGraham  crackers 3  crackers    

tSaltines P  crackers    

fButter  crackers 6  crackers    


Protein 
Grams. 


Rough 
average 
3.0  grms. 


Total 
Calories. 


Rough 
average 
100  cals. 


Section  B — Cereals.     Only  one  article  from  this  table  should  be  used  at  a  meaL 


Food  Article. 


Portion 


Protein 
Grams. 


Rough 


tOatmeal,  boiled 3  heap,  tablesps 

Shredded  wheat 1  biscuit average 

Indian  meal  mush    ....  3  heap,  tablesps [     28  grms 

Hominy,  boiled   2  heap,  tablesps j       '    ° 

Sugar  and  cream  on  cereal  will  add  250  calories. 


Rough 
average 
100  cals. 


Table  VI. 

Nutritious  Soups — High  fuel  value  due  to  carbohydrate  and  fat.  Low  protein. 
Useful  to  increase  the  fuel  value  of  any  meal.  When  one  of  these  is  selected  a 
fruit  dessert  is  desirable. 


Food  Article 

Mock  turtle  soup  4  oz. 

Chicken  soup,  homemade 3  oz. 

Bean  soup,  homemade 4  oz. 

Cream  soups: 

Asparagus    4  oz. 

Celery   4  oz. 

Corn    4  oz. 

Potato 4  oz. 

Tomato 4  oz. 

Pea    4  oz. 


Portion 


Protein 
Grams. 

Total 
Calories. 

6.2          1 

Rough 

9.1 

3.8 

t-      average 
55  cals. 

3.4 

3.0 

Rough 

3.7 

2.8 

average 
125  cals. 

2.9 

6.2 

Xote. — Clear  soups  are  of  low  fuel  value,  and  useful  merely  as  stimulants  to 
flow  of  digestive  juices. 


PLANMyO  DIETS 


83 


Table  VII. 

Desserts — Protein   negligible   to   model  ate.     Fuel   value   high    (carbohydrate). 
Useful  food  articles  to  bring  the  fuel  vahie  of  day's  rations  up  to  the  requirements. 

Food  Article. 

Tapioca  pudding 

Ice  cream 

Doughnuts 

Fruit  cake 

Sugar  cookies 

Apple  pie 

Squash  pie 

Bread  pudding   

Indian  meal  pudding  .  . 

Orange  ice  

Gingerbread 

Chocolate  layer  cake  . . 


Protein 

Total 

Grams. 

Calories. 

3  heap,  tablesps 

5.8 

2  heap,  tablesps 

5.2 

Rough 

1  douglinut 

2.4 

[■  average 

Slice  2%x2%xy2  in... 

1.4 

165  cals. 

3  cookies   

2.3 

3.9         ^ 

Ve  pie 

Ve  pie 

5.8 

2  heap,  tablesps 

5.5 

Rough 

2  heap,  tablesps 

9.0 

L  average 

2  heap,  tablesps 

0.9 

275  cals. 

Slice  2x3x1  in 

3.4 

1  average  slice 

4.3         J 

Table  VIII. 

Fruit — Fuel  value  high  to  moderate  (carbohydrate),  protein  negligible.     Useful 
additions  to  any  and  every  meal  on  account  of  organic  acids,  salts,  and  vitamines. 

Food  Article.  Portion 

Banana 1  average  size 

Grapefruit   %  large  size 

Apple,  baked  1  large  apple 

tApple  sauce  2  heap,  tablesps 

Cranberries,  stewed 2  heap,  tablesps 

Rhubarb,  stewed 2  heap,  tablesps 

Apple,  raw 1  average  size 

Canteloupe %  average  size 

Orange    1  average  size    

fPeach    2  average  size    

Pear    1  average  size    

Blackberries    3  heap,  tablesps 

Strawberries    4  heap,  tablesps 

Raspberries    3  heap,  tablesps 

Pineapple 2  slices 


Protein 
Grams. ' 
1.5          ] 

Total 
Calories 

2.3 

Rough 

.0.6 
0.2 

average 
135  cals. 

0.27 

0.4         -| 

0.4 

1.4 

1.5 

1.2 

Rough 
average 
85  cals. 

0.7         J 

1.3         ^ 
1.0 
0.8 
0.4 

Rough 
[-      average 

45  cals. 

Table  IX. 

Accessories — ^Moderate  to  high  fuel  value  (carbohydrate  or  fat),  negligible 
protein.  Commonly  used  additions  to  every  meal,  and  can  usually  be  expected 
to  add  600  calories  or  more  to  the  day's  ration  without  particular  calculation. 
C — Carbohvdrate.     F — Fat. 


Food  Article. 


Portion 


C.-Sugar,  loaf   1  cube     

Loaf    1  domino    

Granulated     1  heap,    teaspoon. 

C. -Honey     1  tablesp 

C.-Maple  syrup  1  tablesp 

C.-F. -Cream  sauce 3  tablesps 

F.-Olive  Oil   1  tablesp 

F.-Mayonnaise  dressing 1  tablesp 

F.-Cream,  average   1  tablesp 

Heavy   1  tablesp 

Whipped 1  heap,  tablesp.    . 

F.-Butter    1  average  ball    .  . 


Protein 

Total 

Grams. 

Calories 

29 

25 

41 

101 

88 

91 

121 

187 

54 

72 

81 

119 

84 


FOOD  REQUIREMENTS 


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ri  i-ii-(.-i  i-.a>  .-cr-<  c-ic4cir-ioi-i-<iN--ieiie>5 


COC^NOOtOiOCiCO'^tDiOWOt^OOaaO'^C^tOOt^'^O'VCOrfOOOOO 


t^tot^c^oaitootoio 


CO  M  05  oi  to  ic  o>  to  00  to  Ti"  iq  00  lO  C4  c^  o  i^  i-H  CO  ■*  o  _  t--_  oc  ■*  a>  _  ■-;  t;  "^ 

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00  to  o^  f—  as  u'^   lo  (M 


tO-^i-<OOf-<OOOOiCCO'<5*OtOiOO^OtOC*t^OOOOCOtOeOCOtOtOOOOO 
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C5        T-li-CfH^r-i^— .(N-"C<l'-iC-)r-l?q<MeIlr-l         CM—IC^T-lr-li-lr-lC^rll-INt- 


S!NSt~§iSe5e5c5« 


as 


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■S  >  (u  <p  £3  a,s 

x>  a  as:  uuo 
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p. 

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g  fttH  ^!  a>  S 
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03   c3   CO  OQ  w  ■j 

5.5  03  03 is^ 


POOD  REQUIREMENTS 


I    0) 


MO>cOTt<oOT-<r-ia»eooooo 


t^ait>-03iot*t-ooo 


OO  .1 


ooo^Na>oi><et~t»-*t~ 


e-iiMtoooiNeocNeooi-iiH  eooc^oaii-iioooo 


t^  Ci  o  ,c^  t>"  o -^  in  CO  t^ -^  c 
t^  t^  QO  00  !>■  C^  OO  00  to  QO 1:^  a 


o  c 


OOi'^OOOOt^OOClr-tf-l 


ec«OtO'*Oa)Cnoeoc-io 

f-H  r-l  T-H  ,-.    rH       (M    CI  t-t 


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C0»OC0C0lO00lOt*l0I>O  t^COC^COCOCOf-IC-IC^CO 


iC'^'^TCtoo'D'eoooeotf)-^ 


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fl  13  a  a  G 
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o  2;f:;  o  oi  O  PI'S 

OCfcMPnPMpH^ 


PLANNING  DIET8 


89 


teaoaot-r-t~a>aoo>aoaoooooao    oo   «^  oco      .-xoccr 


t^tOe0^iO»-'0-^C^C^iOl--^iHiH»-*C^TT'rHlCiO     CO     r^ 


ooocoo-^or~ooo 

to         00  ^  ^  W  T3<  O**-" 


o>*'Mr-ioo>o>^.-im'«<co-'CiOooc<«!M>-oi.-5   ci   o» 


Mot^-^ticsotOL-at-, 
cooi-ieotoc-<.-iX)r-f 


F-i  ^  ri  M    .  '^  «^      ^ 
ci'ji    'mc<5id«doiod 


CO  CO  cOii'^t^  tococoot^ooi-^oor^t^inr^ccr^r*   t^    co 
■*  eo  «le^  c<  N  e5  M  e^  <N --H  lo  C4  c5  CO  ci  eo  e^  c^  c^  (N   ca   c5 


»c;oc<o>coooococ*J 

.-1  CO  r-l  tH  CD  CI 


oj  "=  oj  OS 

5— .9  3 

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it  -  S  '5  9  ::  J:; 

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a  Boo  fi  gg  a  "  oT 
ti'jojojSSSt;  g-u 

n  n  E_i  t-  *-^  >"  -^  c3  n -f^ 


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I'  >  o  Ji, 


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ig  P.^ 

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—  to  o 


iSPo 
a  >.c;> 

III 

P-X3  D 


Protein  and  Cereal  Portions. — Arnold  has  suggested  the  use  of 
standard  portions  based  on  arbitrary  standards.  The  "protein  por- 
tion" being  equal  to  the  protein  in  one  egg,  8  grams;  the  cereal 
portion  being  the  amount  of  cereal  that  will  contain  4  grams  of  pro- 


90 


FOOD  REQUIREMENTS 


tein.  This  method  may  be  used  to  advantage  where  the  protein 
content  of  the  food  is  the  chief  concern.  Tables  showing  the  vplue 
of  100  grams  of  various  foods  will  be  found  of  use  in  this  connection: 


Protein   Portion. 

p. 

F. 

C. 

Gal. 

8 

5 

5 

100 

Average  portion. 

8 

5.5 

80 

Egg.  1- 

8 

8 

8 

140 

Milk.  1  glass   (200  cc). 

7.5 

1.25 

1.25 

100 

Buttermilk,  i  pt. 

8 

5 

80 
Ce) 

Meat  or  fish,  IJ  ozs.,  or  one-third  serving 
eal    Portion. 

P. 

F. 

C. 

Cal. 

Cooked  foods. 

4 

1 

30 

140 

Average   portion. 

4 

2 

24 

135 

Cereal,  4  tablespoons. 

4 

60 

240 

Rice,  4  tablespoons. 

4 

2 

20 

120 

Macaroni,  4  tablespoons. 

2 

2 

20 

120 

Vermicelli,  4  tablespoons. 

4 

40 

180 

Potatoes,  2  moderate  sized. 

3 

0.5 

15 

80 

Bread,   1   oz.    (or  slice). 

3 

3 

20 

120 

Crackers,  1  oz. 

3 

0.5 

22 

100 

Shredded  wheat,   1  biscuit. 

An  Ideal  Ration  of  Liquid  Food. — {Mrs.  E.  H.  Richards.) 


Material. 


Beef  broth  or  consomm^ 

To  which  has  been  added 
one  large  egg  minus 
shell 

Dried  fruit  soup  .... 

Lemon  jelly 

Whole  milk 

Kice  or  arrowroot    .    .    . 

Grape-sugar  or  some  one 
of  the  prepared  foods 
(dry) 

Total 


Amount. 


1  pint 


2  ounces  . 
1  quart .  . 
^  pint  .  . 
1  quart .    . 

3  oz.  (dry) 


4  oz.  (dry) 


2.5-3  qt.» 


Proteid. 


6m. 
20.5 


4.1 

'e.'s 

34.0 
6.3 


2.5 


76.9 


Fat. 


Gm. 
0.5 


6.8 


36.0 
0.3 


43.6 


Carbo- 
hydrates. 


Gm. 


100.0 
12.5 
44.0 
67.2 


100.0 


323.7 


Calories. 


91.67 
410.00 

77.90 
651.00 
304.11 


420.25 


2043.63 


While  diet-lists  are  easily  prepared  according  to  the  method  just 
outlined,  it  must  always  be  remembered  that  the  digestibility  and 
absorbability  of  food  play  a  most  important  role,  and  are  not  to  be 
neglected  in  formulating  the  dietary;  for  while  a  certain  food  may 
contain  a  great  many  more  calories  than  an  equal  weight  of  another 
food,  yet  its  relative  indigestibility  and  non-absorbability  maj^  render 
it  far  less  available  as  an  article  of  diet.  For  example,  while  4  ounces 
of  sausage  produce  510  calories,  4  ounces  of  cheese  520,  and  4  ounces 
of  beef  only  280,  yet  the  beef  is  far  more  digestible  than  either  the 
sausage  or  cheese,  and  thus  more  valuable  as  an  article  of  food.  As 
has  been  aptly  said,  "We  live  not  upon  what  we  eat,  but  upon  what 
we  digest. ' '  Therefore,  a  diet-list  giving  quantities  of  food  principles 
or  calories  is  useful  only  as  it  suggests  general  principles  that  may 

1  According  to  how  the  rice  is  given. 


PLANNING  DIETS 


91 


be  modified  to  meet  individual  conditions  in  health  and  in  disease. 
The  following  table  of  Roberts  ^  will  be  found  of  value  in  computing 
diet: 


<% 


■5k2 


■'  3 

3 

O  to 

C 

c  o 

Oj 

O  3 

a^ 

"d 

?J 

5 

be  p. 

SaS 

a 

S-2 

si  J 

e<5 


5  0iOtCCO       lOOiOOOOOp 
r!      ■  ■-<■  rt      ■  O      ■  CO  r-i  oi  <0  lO  ■-!  rH 


OOOl^OOOOiO 


OOOCCOOOOiCOOinOOOOOOOi-OO 


O  rH 


d  a  a  c 
o  o  o  o 
o  o  o  o 


^    ^   ^   Oj    3^    ^    Cd 

^  ^  w  3;)  4)  a;  iD 


0-0.5  « 
a>  0)  S  ^ 


a)  c3 
^  o 


can  5  ceca^ 

coo  9  OOCOq 

g.g.a  g  p.o.p.c.g 

CJ  0^  ^  O  V  Cl(  <y  o  G^  (U  *"* 

ggaca  ;^     o-S  aaae^p, 

•"•'"'"■"'-  00     3  gi,  S.S.S.S."-'^ 


cafl<i'a)<DeacaSa>aaji222CgH 


CQ  U  UQ 

s  a  N 

3  3-3 
O)  0)  d 

aa5 


dflS 

o  o  a 


NNaaaaa  NasNaNNaa 

o  o  bCbcbobobs     o  bcbco  boo  o  bJObc 

0000>COOOO        iCOOOOrHrt  i-HOQ 

(NN.-ir-(i-i  i-i;s 


aaasaaaaaaaaaaaaaa 

bobi:bi:bi)bcb£bcb£bcbiibcb(ibcb£bj]bcbbbo 

OOOOOOOiQiCOOI^O»^i^iO»COO 


aaaa 

be  be  be  bO 

OiOOO 


S  OJ  OJ 


Soo«5(jc3Sh 


_,„-ac^>.-S.a=5^ 

aJsjoSajS;r;g-ojB.r 


1  Jour,  of  the  Amer.  Med.  Assoc,  April  21,  1906. 


92 


FOOD  REQUIREMENTS 


Other  valuable  tables  will  be  found  in  the  various  sections  relating 
to  diseases,  especially  in  the  one  on  diabetes. 

The  following  instructive  table  is  taken  from  Sutherland's  System 
of  Diet  and  Dietetics: 


^ 


II 


a 


b    43 


;  O  £  y 

2  1^ 


a;  ^  "  o^  S 

o^tK    com 


0)   M 

•^^ 

C  O  £ 
O  U  OJ 

»^  a  u 

t3 


^  gfl  ff^'Sfl  g"^  £^  g^  §J3  S<^.22-3  o  g 

y-  2  "  O  «^  "^  1-  ^£  =.'5  <^  a  "  o  "  oj  03^  O  §  ' 

^o    o    o    o    o    o    <;    e3    «p^oo 


Si^ 


pn 


a>  J 


;'0      "O 


Pi    w    Ph       o    ■■-     '-  '^ 


a>      oj  —    , 


„ii  o  2  B  S  S  S  S  ' 


fe-^-o-::  E  "  =      .  o  ~  .  <D  4) 
-<!     pa  '^fL,        C H 


i  §.S  ^^  S-g  ^ 


■O  oj--:;  bi>a  a)_^  to-^  -  ti 
Q      ^      S      p:i-3     u 


m  CO    .  2       S  ,    <l>  bo        . 


0)  o 
S  ^^5'5'§'0  So  OS 


. S s'^'s g"n S-g a   -a; 

o  2  bo'S'T? 


CLASSES  OF  FOODS 

ANIMAL  FOODS 

Animal  foods  contain  much  digestible  matter,  chiefly  proteins,  a 
considerable  quantity  of  fat,  in  some  foods  carbohydrates,  and,  in 
addition,  water  and  mineral  salts.  Being  thoroughly  digested,  they 
leave  but  little  residue  in  the  intestine.  The  various  forms  of  animal 
foods — milk,  eggs,  meat,  fish,  and  gelatin — will  now  be  described 
under  these  headings. 

MILK  AND  MILK  PRODUCTS 

Milk,  the  most  important  of  animal  foods,  contains  all  the  elements 
necessary  for  the  maintenance  of  life,  and  constitutes  a  complete 
food. 

Composition. — Milk  contains  varying  proportions  of  each  of  the  four 
classes  of  food  principles,  protein,  fats,  carbohydrates,  and  mineral 
salts,  and  from  84  to  90  per  cent,  of  water;  this  latter  varying  with 
the  quality  of  the  milk.  In  a  general  way  this  is  true  of  all  milks, 
which  are  more  or  less  alike,  but  which  contain  different  percentages 
of  the  constituents. 

Milk  forms  the  exclusive  diet  for  the  young,  growing  mammals, 
but  owing  to  the  fact  that  the  proportions  of  proteins  and  fat  are 
in  excess  of  the  carbohydrates,  it  is  unsuited  as  an  exclusive  diet  for 
adults.  Unless  otherwise  stated  cows'  milk  is  meant  by  milk  in  this 
volume.  Cows'  milk  is  most  extensively  used  for  food,  but  the  milk 
of  goats  and  asses  and  some  other  animals  is  used  to  some  extent. 

Fresh  cows'  milk  has  a  sweetish  taste,  a  characteristic  odor,  and  is 
yellowish-white  in  color;  on  standing  it  separates  into  two  distinct 
layers,  the  upper  being  more  yellow  in  color,  of  lighter  specific  gravity, 
and  containing  more  fat.  For  dietetic  purposes  it  is  well  to  think 
of  cream  as  a  milk  containing  varying  percentages  of  fat.  The  lower 
part,  called  "skim'  milk"  after  the  removal  of  the  cream,  is  of  a 
bluish-white  color,  and  may  be  considered  relatively  free  from  fat. 
The  specific  gravity  of  milk  varies  from  1.027  to  1.035  and  it  freezes 
at  a  slightly  lower  temperature  than  water. 

There  are  numerous  statements  and  theories  concerning  the  reaction 
of  cows'  and  human  milk.  Freshh'  drawn,  the  milk  of  most  carnivora 
is  acid  to  the  litmus  reaction ;  human  milk  is  alkaline,  sometimes  acid 
or  amphoteric,  and  cows'  milk  amphoteric — turning  red  litmus  blue 
and  vice  versa.  On  exposure  to  the  air  all  milks  will  turn  blue 
litmus  red,  owing  to  the  conversion  of  the  milk-sugar  into  lactic  and 
other  acids. 

93 


94 


CLASSES  OF  FOOD 


'Cij 


g    ^< 


M 

1 

o 

o 

o 

o 

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^ 

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n 

> 

s 

X 

n 

■"" 

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1-1        o 

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r-  a)  a 

00          I-H 

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15 1? 
czo 

u-;  o  o  t~  —  i^  o  o 

C^  l^  ^  >—  O  Ct  l^  o 

.-i  O  •-;  O  O  O  -^  1-; 

o  o  c  o  o  o  o  o 


s    * 


11.1° 

ts-d  fl  ^5  g  S  w 
g,-«  a  o  o  s  -c 

SCO  ;3        --_ 


'55  "Sc 


.o  ' 


p  oj.:: 


c'S-E.s  a'Eg'B-c-S  §  o  o.S         .    ,, 

—  a32.C=  =  s  OS  =s  S-^  S  =s.~     E.t;  o  o^J*  P  3^.;: 


The  microscopic  examination  with  a  low  power  shows  the  fat  globules 
and  some  leukocytes  and  foreign  matter  if  present;  with  the  im- 
mersion lens  the  bacterial  contents  may  be  studied. 


ANIMAL  FOODS  95 

Kastle  and  Roberts  give  the  scheme  on  p.  94,  compiled  by  Van 
Slyke  and  Babcock. 

The  principal  nitrogenous  compound  of  milk  is  casein,  which  differs 
from  the  other  protein  compounds  in  that  it  contains  both  phosphorus 
and  sulphur.  Casein  is  not  coagulated  by  heat,  but  this  change  may 
be  effected  by  adding  acid  or  rennet.  The  casein  clot  formed  by 
adding  acids  may  be  dissolved  by  neutralizing  the  acid,  while  that 
formed  by  rennet  is  not  affected  by  the  addition  of  an  alkali. 

Milk  also  contains  other  proteins,  as  lactalbumin,  which  is  similar 
to  the  serum-albumin  of  the  blood,  lactoglobulin,  and  lactomucin. 
The  total  proteins  average  about  3.3  per  cent,  of  the  bulk  of  the  milk, 
or  about  25  per  cent,  of  the  total  solids. 

The  fats  of  milk  consist  of  the  giycerids  of  palmitic,  stearic,  and 
oleic  acids.  In  addition  to  these,  milk  contains  several  other  fats  in 
smaller  proportions,  to  which  the  flavor  of  butter  is  in  part  due.  The 
fat  is  suspended  in  the  milk  in  the  form  of  minute  globules,  which 
give  the  milk  its  white  color  and  opacity.  The  fat  globules  in  some 
milks  are  larger  than  in  others.  They  are  smallest  from  a  herd  of 
mixed  common  cows  and  largest  in  the  milk  of  Jerseys  and  Guernseys. 
Fat  averages  about  4  per  cent,  of  the  milk,  or  about  31  per  cent,  of 
the  total  solids. 

The  chief  carbohydrate  of  milk  is  lactose,  or  milk-sugar,  which  is 
not  nearly  so  sweet  as  ordinary  sugar,  and  is  less  ■  soluble  in  water. 
It  reacts  to  Fehling's  solution  like  glucose,  and  in  the  presence  of 
the  lactic  acid  bacillus  it  is  converted  into  lactic  acid,  which  causes 
the  milk  to  turn  sour.  Lactose  forms  about  38  per  cent,  of  the  total 
solids. 

Milk  contains  about  0.7  per  cent,  of  salts,  which  exist  chiefly  in  the 
form  of  phosphates,  chlorids,  and  sulphates.  Potassium  salts  occur  in 
larger  quantities  than  do  sodium  salts. 

Calcium  salts  are  very  essential  to  young,  growing  animals,  inas- 
much as  they  play  a  very  important  part  in  the  formation  of  bone. 
The  relative  percentages  of  salts  in  the  ash  of  human  milk  are  shown 
by  the  following  table : 

Caleiiun  phosphate    23.87 

"         sulphate     2.25 

"         carbonate     2.85 

"         silicate   1.27 

Potassium   carbonate    23.47 

chlorid     12.05 

"            sulphate    8.33 

Magnesium    carbonate    3.77 

Sodium   chlorid    21.77 

Ferric  oxid  and  aluminum 0.37 

100.00 

When  the  cow  is  diseased,  various  substances  not  present  in  normal 
milk  may  be  discovered,  as  urobilin  and  bile.     Milk  may  also  contain 


96 


CLASSES  OF  FOOD 


odoriferous  substances  from  things  which  the  cow  has  eaten,  as  wild 
garlic.     Milk  also  absorbs  odors  from  the  air. 

Variations  in  Milk. — There  are  wide  variations  in  the  composition 
of  the  milk  of  different  animals.  While  human  milk  contains  more 
sugar  and  less  protein  than  cows'  milk,  the  fuel-value  is  about  the 
same.  Dogs'  milk  seems  to  be  the  richest,  whereas  that  which  comes 
from  the  horse  is  exceedingly  poor,  as  may  be  seen  from  the  following 
table : 

Comparative  Composition  of  Various  Kinds  of  Milk} 


Water 

Total 
solids. 

Total  solids. 

Kind  of 

Protein. 

Fat. 

Carbo- 
hydrates 
(milk- 
sugar). 

Mineral 

matters 

(ash). 

Fuel- 
value  per 
pound. 

milk. 

Casein. 

Albu- 
min. 

Total 
pro- 
tein. 

Woman 
Cow   .  . 
Dog    .  . 
Ewe 
Buffalo . 
Cat.  .   . 
Goat  .  . 
Llama  . 
Ass.  .  . 
Hare  .  . 

Perct. 
87.4 
87.2 
75.4 
80.8 
81.4 
82.1 
8.=S.7 
86.5 
89.6 
91.5 

Perct. 
12.6 
12.8 
24.6 
19.2 
18.6 
17.9 
14.3 
13.5 
10.4 
8.5 

Per<A. 
1.0 
3.0 
6.1 
5.0 
5.8 
3.1 
3.2 
3.0 
0.7 
1.2 

Perct. 
1.3 
0.5 
5.1 
1.5 
0.3 
6.0 
1.1 
0.9 
1.6 
0.1 

Perct. 

2.3 

3.5 
11.2 

6.5 

6.1 

9.1 

4.3 

3.9 

2.3 

1.3 

Perct. 
3.8 
3.7 
9.6 
6.9 
7.5 
3.3 
4.8 
3.2 
1.6 
1.2 

Perct. 
6.2 
4.9 
3.1 
4.9 
4.1 
4.9 
4.4 
5.6 
6.0 
5.7 

Per  et. 
0.3 
0.7 
0.7 
0.9 
0.9 
0.6 
0.8 
0.8 
0.5 
0.3 

Calories. 
319 
313 
671 
503 
506 
400 
365 
312 
222 
180 

Not  only  is  there  a  wide  variation  in  the  milk  of  different  animals, 
but  cows'  milk  itself  is  subject  to  great  changes  in  the  percentage 
composition  of  its  ingredients.  These  may  be  attributed  to  many 
causes,  the  breed  and  condition  of  animals  and  the  food  and  the  care 
they  receive  being  responsible  in  a  great  degree  for  these  changes. 
As  a  rule,  a  young  cow  gives  better  milk  than  an  old  one,  and  a  well- 
fed  animal  yields  richer  milk  than  one  that  is  poorly  fed.  The  milk- 
flow  is  greatest  shortly  after  calving,  but  the  milk  increases  in  rich- 
ness as  the  quantity  becomes  smaller. 

Milk  Ferments. — Milk  contains  numerous  ferments,  to  which  con- 
siderable attention  has  been  devoted  of  late  years.  Marfan  believes 
that  these  ferments  probably  make  up  for  the  deficiencies  of  the 
glandular  secretions  in  the  newborn,  and  that  there  may  be  specific 
ferments,  which  explains  the  desirability  of  milk  of  a  particular 
species  as  food  for  animals  belonging  to  it.  The  principal  ferments 
are  proteolytic  ferments,  resembling  trypsin,  but  less  sensitive  to 
acids ;  fat-splitting  ferments,  lipase,  amylase,  peroxidase,  and  catalase. 

The  Action  of  Heat. — The  amount  of  change  taking  place  in  milk 
on  heating  depends  upon  the  degree  of  heat  and  the  length  of  ex- 
posure. Heating  up  to  60°  C.  does  not  appreciably  change  the  ap- 
pearance or  taste,  although  some  changes  which  defy  detection  evi- 
dently occur.     When  the  milk  reaches  a  little  over  60°   C.  a  scum, 

1  Konig,  Chemie  der  menschlichen  Nahrungs-  iind  Genussmittel.  3  ed.,  vol.  i., 
pp.  267-362. 


i 


ANIMAL  FOODS  97 

composed  largely  of  fatt}'  matter  aud  casein,  forms  on  the  surface. 
Acid  milks  are  coagulated  much  more  easily  and  more  quickly  than 
milk  which  is  not  acid,  and  even  when  pasteurized  at  a  low  tempera- 
ture such  milks  may  clot.  In  order  to  prevent  this,  milk  should  be 
pasteurized  as  soon  after  milking  as  possible.  Boiling  milk  changes 
its  taste  and  color,  the  cream  will  not  rise  as  quickly,  if  at  all,  and 
it  is  less  easily  coagulated  by  the  action  of  rennet  and  less  easily 
pancreatized.  The  change  in  color  is  due  to  the  production  of  a  cer- 
tain amount  of  caramel  from  the  milk-sugar ;  lecithin  and  nuclein  are 
decomposed,  lessening  the  amount  of  organic  phosphorus  present  and 
increasing  the  inorganic  phosphorus;  the  calcium  and  magnesium 
salts  and  part  of  the  phosphates  are  precipitated;  the  carbon  dioxid 
is  driven  off,  some  of  the  fat  globules  coalesce,  and  the  serum-albumin 
is  coagulated ;  the  ferments  of  the  milk  are  also  destroyed.  Although 
these  enzymes  will  withstand  a  temperature  of  60°  C.  for  an  hour 
without  much  injury,  most  of  them  are  totally  destroyed  by  a  tem- 
perature of  65°  C,  and  the  most  resistant  by  a  temperature  of  76°  C. 

Frozen  Milk.- — Freezing  milk  is  sometimes  resorted  to  as  a  means 
of  keeping  it  during  transportation.  It  should  be  kept  frozen  until 
used.  While  this  method  is  employed  in  some  places,  it  has  never 
come  into  anything  like  general  use. 

Cold  storage  of  milk  is  frequently  resorted  to,  but  when  the  milk 
is  kept  at  a  temperature  of  about  0°  C.  there  is  very  considerable 
growth  of  bacteria,  especially  of  certain  varieties  that  flourish  at  low 
temperatures.  A  very  complete  study  of  this  subject  has  been  made 
by  Pennington,^  to  which  the  reader  is  referred  for  details.  In  such 
milk  the  bacteria  increase  in  number  for  five  or  six  weeks,  and  after 
that  certain  species  die  out,  while  the  most  resistant  apparently  are 
present  even  for  years.  The  acidity  is  very  much  increased,  although 
curd  rarely  separates.  The  protein  of  the  milk  is  digested,  and  in 
some  cases  as  much  as  50  per  cent,  is  changed  into  soluble  compound. 

Pregnancy  in  the  Cow  and  the  Use  of  Milk. — Up  to  ten  days 
before  calving  the  milk  is  generally  safe  for  use,  but  if  very  visibly 
altered  it  should  not  be  used  and  the  cow  may  go  dry  before  that 
time.  After  calving  the  milk  is  normal  after  ten  days  time;  before 
that  the  composition  may  be  altered  by  the  presence  of  colostrum. 
The  rule  of  the  Walker-Gordon  Company  is  to  exclude  the  milk  for 
three  weeks  before  the  expected  calving  and  for  ten  days  afterwards. 

Sterilization  and  Pasteurization. — Heat  is  employed  very  fre- 
quently in  keeping  milk,  and  there  are  two  methods  in  vogue,  spoken 
of  as  sterilization  and  pasteurization. 

Sterilization  of  milk  is  accomplished  either  by  boiling,  preferably 
in  the  vessel  in  which  it  is  to  be  kept,  or  by  placing  the  bottles  in  one 
of  the  numerous  forms  of  sterilizers  that  are  on  the  market.  The 
essential  part  of  the  process  is  that  the  milk  be  heated  to  212°  F. 
and  maintained  at  that  temperature  for  ten  minutes  or  longer,  or 

1  Journal  of  Biological  Chemistry,   198,  p.  353. 


98  CLASSES  OF  FOOD 

sufficient  to  kill  all  the  living  bacteria  which  the  milk  contains.  It 
is  to  be  noted,  however,  that  the  spores  of  spore-bearing  bacteria  are 
not  killed  by  this  temperature,  and  that  if  the  milk  is  kept  under 
suitable  conditions  for  bacterial  growth,  bacteria  will  develop  from 
the  spores,  and  the  milk  may  spoil  in  consequence.  In  order  to  secure 
perfectly  sterile  milk  it  is,  therefore,  necessary  to  repeat  the  steriliza- 
tion three  times  on  three  successive  days.  In  practical  work  this  is 
rarely  done,  except  in  the  production  of  culture-media  for  bacterial 
researches  or  in  preparing  milk  for  long  voyages.  Ordinarily,  milk 
heated  once  and  then  kept  cold,  40°  F.  or  under,  will  keep  perfectly 
well  the  length  of  time  required  in  its  ordinary  consumption.  There 
are  certain  objections  to  sterilized  milk.  Certain  changes  are  pro- 
duced in  the  milk  which  are  detailed  under  the  heading  of  the  "Ef- 
fects of  Heat."  Sterilizing  also  kills  off  the  ferments  and  places  the 
milk  in  the  class  of  lifeless  foods.  Sterilizing  on  a  large  scale  has 
never  become  popular  in  America,  perhaps  on  account  of  the  change 
in  taste  and  the  added  expense.  It  may  be  used  w^ith  advantage, 
however,  in  keeping  milk  in  very  hot  weather,  especially  when  the  ice 
supply  is  deficient. 

By  pasteurization  is  meant  the  process  by  which  the  milk  is  rendered 
morewor  less  sterile  by  heating  to  167°  F.,  and  in  some  instances  to 
a  lower  temperature,  maintaining  this  degree  of  heat  for  from  twenty 
to  forty-five  minutes,  and  then  cooling  the  milk  rapidly  to  40°  or 
45°  F.  or  lower.  This  degree  of  temperature  is  sufficient  to  kill  off 
most  of  the  bacteria  and  especially  the  pathogenic  bacteria,  but  it 
does  not  render  the  milk  absolutely  sterile,  so  that  it  does  not  keep 
as  well  as  that  which  has  been  heated  to  a  higher  temperature.  It 
has  the  advantage,  however,  of  not  changing  materially  the  composi- 
tion of  the  milk.  Pasteurized  milk  should  be  kept  cold  or  it  will  spoil 
nearly  as  rapidly  as  unheated  milk.  It  is  useful  in  summer  and 
in  keeping  milk  which  is  to  be  fed  to  babies,  and  is  being  used  at  the 
present  time  very  extensively  for  keeping  commercial  milk.  In  the 
househokl.  for  the  purpose  of  infant  feeding,  pasteurization  is  done 
in  two  ways.  Best,  by  using  one  of  the  special  forms  of  pasteurizers, 
such  as  Freeman's,  which  consists  of  two  parts,  a  pail  for  the  water 
and  receptacle  for  the  bottles  of  milk.  The  pail  is  a  simple  pail  with 
a  cover:  there  is  a  groove  extending  around  the  pail  to  indicate  the 
level  to  which  it  is  to  be  filled  with  water,  and  supports  inside  for  the 
receptacle  for  the  bottles  of  milk  to  rest  on.  The  receptacle  for  the 
bottles  of  milk  consists  of  a  series  of  hollow  zinc  cylinders  fastened 
together;  this  fits  into  the  pail,  so  that  the  lower  inch  of  the  cylinders 
is  immersed  in  the  w^ater.  This  receptacle  has  two  sets  of  horizontal 
supports,  the  upper  set  continuous  around  the  receptacle,  for  use 
while  the  milk  is  being  heated ;  the  lower  interrupted  set  is  used  for 
raising  the  receptacle  during  cooling.  Such  receptacles  are  made 
for  ten  6-ounce  bottles,  .seven  8-ounce  bottles,  three  1-pint  and  one 


[ 


AMMAL  FOODS  99 

i/{>-pint  bottles,  and  two  1-qiiart  bottles.  Tbere  is  also  a  large  ap- 
paratus for  the  use  of  hospitals  or  public  institutions,  which  has  a 
receptacle  for  forty-three  6-ounce  or  8-ounce  bottles. 

The  apparatus  is  useti  in  the  foUowiuo;  way:  The  pail  is  iilled 
to  the  level  of  the  groove  with  water,  covered  aiul  put  on  the  stove, 
the  receptacle  for  the  bottles  being  left  out.  The  bottles  of  milk  are 
then  filled,  stoppered  with  cotton,  and  dropped  into  their  places  in 
the  cylinders.  Sufficient  water  is  poured  into  each  cylinder  to  sur- 
round the  body  of  the  bottle.  As  soon  as  the  water  in  the  pail  boils 
thoroughly,  it  is  taken  from  the  stove  and  set  on  a  mat  or  table  or 
other  non-conductor  in  a  p4ace  where  there  is  not  a  draft  of  wind 
blowing  on  it.  The  lid  of  the  pail  is  removed  and  the  receptacle  rests 
on  the  lower  supports.  The  lid  is  then  rapidly  put  on  the  pail,  and 
the  pail  is  thus  allowed  to  stand  for  three-quarters  of  an  hour.  Dur- 
ing the  first  fifteen  minutes  the  temperature  of  the  milk  rises  to  about 
its  maximum,  or  above  65°  C,  the  point  desired  for  pasteurizing,  and 
remains  there  the  remaining  thirty  minutes.  During  the  last  fifteen 
minutes  the  cover  of  the  pail  is  removed,  the  receptacle  is  lifted  and 
given  a  tnrn  so  as  to  rest  on  the  upper  sup[)orts,  thus  bringing  the 
top  of  the  cylinders  containing  the  bottles  above  the  level  of  the  pail. 
The  pail  is  then  put  under  a  cold-water  faucet  and  the  water  is 
allowed  to  run  into  the  pail  and  overflow,  but  it  should  not  ritn  into 
the  cylinders.  Thus  the  hot  water  is  replaced  by  cold  water,  and 
in  fifteen  minutes  the  milk  in  the  bottles  is  of  about  the  temperature 
of  the  cold  water  used.  The  bottles  ma.y  then  be  put  into  a  refrigera- 
tor until  required  for  feeding.  This  rapid  cooling  is  a  most  necessary 
part  of  a  low-temperature  sterilization,  the  importance  of  which  is 
apt  to  be  overlooked. 

When  there  is  no  special  apparatus  at  hand,  reasonably  good  results 
may  be  obtained  by  placing  the  milk  bottles  in  a  pail,  filling  the  pail 
to  the  height  of  the  milk  in  the  bottles  and  bringing  nearly  to  a  boil, 
then  setting  to  one  side  for  thirty  minutes.  In  commercial  pasteuriza- 
tion, special  forms  of  apparatus  are  used,  in  which  large  quantities  of 
milk  may  be  heated  the  required  temperature  for  twenty  minutes. 

The  advantages  of  pasteurization  are  that  it  is  a  cheap  and  ett'ective 
method  of  preventing  the  ordinary  infectious  diseases  which  may  at 
times  be  spread  by  milk,  and  doubtless  lessens  the  number  of  cases  of 
infantile  diarrhea.  It  should  be  remembered  that  pasteurization  can- 
not make  bad  milk  good  or  dirty  milk  clean,  and  when  used  for 
infants  or  invalids  it  must  be  modified  in  the  same  manner  as  un- 
heated  milk. 

The  disadvantages  of  pasteurized  milk  are,  that  it  is  usually  done 
a  long  way  froui  the  place  of  production,  the  milk  may  be  spoiled 
before  it  is  pasteurized,  and  while  the  bacteria  are  for  the  most  part 
killed,  the  toxins  which  may  have  been  formed  are  not  destroyed,  and 
so   dangerous  milk  may  be   sold   for   good  milk.     This   is,   however, 


100  CLASSES  OF  FOOD 

counterbalanced  by  the  real  lessening  of  infantile  diarrhea.  Another 
disadvantage  is  that  the  milk  producer  is  apt  to  become  careless  and 
trust  to  pasteurization  to  kill  off  the  bacteria  instead  of  using  cold 
and  cleanliness.  Pasteurized  milk  is  popularly  supposed  to  be  less 
digestible  than  unheated  milk,  especially  for  infants.  The  difference 
in  digestibility  of  pasteurized  and  unheated  milk  is  certainly  slight, 
but  the  best  results  in  infant  feeding  are  obtained  by  the  use  of  un- 
heated milk.  We  are  of  the  decided  opinion  that  unheated  milk  is 
far  superior  in  the  long  run,  where  it  can  be  obtained  of  sufficient 
purity  to  permit  of  its  use.  There  are  other  objections  sometimes 
urged  against  heated  milk,  such  as  it  favors  the  development  of 
scurvy.     This  is  evidently  true,  but  is  a  lesser  evil  than  diarrhea. 

Sterilizing  milk  under  pressure  is  rarely  resorted  to  outside  of 
laboratories.  A  temperature  of  220°  F.  for  thirty  minutes  is  or- 
dinarily considered  to  produce  sterile  milk,  but  sometimes  even  this 
is  insufficient. 

The  loss  in  viscosity  in  sterilized  and  pasteurized  cream,  rendering 
it  thinner  and  difficult  to  whip,  may  be  counteracted  by  a  material 
called  viscogen,  suggested  by  Babcock  and  Russel.  It  consists  of  a 
mixture  of  half  an  ounce  of  cane-sugar  in  a  quart  of  lime-water.  It 
is  allowed  to  settle  and  the  clear  fluid  used  in  the  proportion  of  about 
two-thirds  the  amount  needed  to  neutralize  the  cream.  This  may  be 
easily  determined  by  titration. 

Digestion  of  Milk. — When  milk  enters  the  stomach  it  is  coagulated 
by  the  hydrochloric  acid  and  the  rennin  of  the  gastric  juice.  These 
curds,  or  coagula,  consist  of  precipitated  casein  and  a  proportion 
of  the  fat  that  has  become  entangled  in  the  curd.  They  vary  in  size 
and  consistence  according  to  the  amount  and  the  dilution  of  the  milk 
taken.  The  casein  soon  undergoes  change,  being  converted  into  some 
form  of  peptone,  and  the  fat  is  again  liberated.  The  albuminous 
envelope  of  the  fat-globules  is  dissolved,  and  the  fat  coalesces,  form- 
ing larger  drops,  in  which  condition  it  passes  into  the  duodenum.  A 
portion  of  the  water  and  some  of  the  salts  are  absorbed  in  the  stom- 
ach. The  curd  that  has  not  been  acted  upon  by  the  gastric  juice, 
together  with  the  water,  salts,  and  carbohydrates  that  still  remain, 
also  pass  into  the  intestine,  where  their  digestion  is  completed.  Boil- 
ing increases  the  digestibility  of  milk,  the  precipitate  being  deposited 
in  a  more  flocculent  form.  If  the  milk  is  previously  ^il^^ted  with 
lime-water,  barley-water,  or  one  of  the  aerated  waters,  such  as  Vichy, 
the  curds  formed  are  smaller  and  softer,  and  the  milk  often  rendered 
more  palatable.  Bread  and  crackers  added  to  milk  make  a  good 
mechanical  diluent  by  mingling  with  it  and  maintaining  a  soft  condi- 
tion of  the  curds.  The  addition  of  alkalis  may  be  resorted  to  vnth  a 
view  to  neutralizing  the  acids.  This  has  the  effect  of  coagulating  the 
casein  more  slowly,  and  forming  flocculi  rather  than  cheesy  masses. 

The  Color  of  Milk. — Various  changes  in  the  color  of  milk  are  not 


ANIMAL  FOODS  101 

uncommon,  the  best  known  of  which  is  blue  milk,  and  while  it  rai-eiy 
occurs  in  clean  and  well-kept  dairies,  it  is  not  unfrequently  seen  in 
milk  which  is  poorly  handled  and  exposed  to  contamination.  The 
color  is  due  to  the  action  of  bacteria,  one  described  as  the  Bacillus 
cyanogenes  being  perhaps  most  fre(iueutly  present.  The  milk  turns 
blue  in  spots  and  finally  assumes  a  diffuse  sky-blue  color.  Red  milk 
ma}^  be  due  to  the  presence  of  blood  due  to  injuries  of  the  udder  or 
mammary  gland,  to  the  cows  having  fed  on  plants  containing  red 
pigments,  such  as  the  madder  plant,  and  more  rarely  to  the  action  of 
bacteria,  of  which  there  are  several  that  will  produce  a  red  color,  the 
best  known  of  which  is  the  Bacillus  prodigiosus.  Green,  yellow, 
chocolate,  and  black  milk  have  been  described,  which  are  due  to  various 
forms  of  bacteria. 

Slimy  or  Ropy  Milk. — This  is  a  very  curious  change  which  oc- 
casionally takes  place  in  milk  and  is  due  to, the  action  of  bacteria,  one 
described  as  the  Bacillus  lactis  viscosi  being  perhaps  the  best  known. 
The  change  is  seen  also  in  certain  diseases  of  the  mammary  gland. 
The  milk  becomes  slimy  or  ropy,  and  can  be  drawn  out  into  long  thin 
threads,  even  as  long  as  ten  feet.  In  some  countries,  particularly 
Norway,  slimy  milk  is  produced  by  the  addition  of  certain  leaves  to 
the  milk  and  the  product  is  esteemed  as  a  food.  The  leaves  contain 
the  slime-producing  bacteria.  This  change  is  also  induced  for  the 
manufacture  of  certain  cheeses,  particularly  Edam. 

Bitter  milk  is  very  common,  most  frecjuently  being  caused  by  the 
cows  having  fed  on  plants  containing  bitter  substances,  chiefly  the 
lupines ;  it  occurs  also  during  the  last  stages  of  lactation ;  is  sometimes 
caused  by  abnormal  conditions  of  the  udder,  and  may  be  protluced  by 
the  presence  of  certain  forms  of  bacteria. 

Alkaline  Fermentation  of  Milk. — ^lilk  which  has  been  boiled  does 
not  sour  through  spontaneous  fermentation ;  but  if  exposed  to  the  air 
at  ordinary  temperature  it  becomes  alkaline  in  reaction,  sometimes 
develops  a  bitter  taste,  and  then  curdles.  Later  on  the  curd  dissolves 
and  a  more  or  less  clear  fluid  is  left  which  has  no  resemblance  what- 
ever to  milk.  There  are  a  number  of  different  bacteria  which  may 
produce  this  change. 

Flavors  in  Milk. — The  flavor  of  milk  may  vary  from  time  to  time. 
This  may  be  due  to  the  food,  such  things  as  wild  onion,  even  in  small 
quantities,  affecting  the  flavor  of  the  milk  very  markedly,  and  dis- 
orders in  the  cow  may  also  cause  unusual  flavors  for  a  few  days. 
Milk  also  absorbs  odors,  and  if  kept  in  an  ice-box  with  odoriferous 
substances  it  may  take  on  their  flavors.  The  growth  of  bacteria  also 
alters  the  taste  of  milk  very  materially,  and  may  impart  many  differ- 
ent flavors  to  it. 

Bacteria  in  Milk. — Milk  is  a  most  excellent  culture-media  for 
bacteria,  and  most  germs  grow  luxuriously  in  it  at  the  expense  of 
the  quality  of  the  milk.     The  changes  produced  are  largely  those  of 


102        _    .•  .'."\\      ;    "       "^LASSES  OF  FOOD 

decomposition,  and  many  of  them  are  exceedingly  complex,  resulting 
in  the  production  of  changes  in  flavor,  odor,  color,  and  the  quality  of 
the  milk.  The  proteins  may  become  decomposed,  the  sugar  converted 
into  gases,  alcohol,  or  acids,  while  the  fats  are  but  little  changed. 

The  number  of  bacteria  in  milk  varies  greatly,  the  very  best  milk 
containing  but  a  few  thousand  bacteria  per  cubic  centimeter,  while 
very  poor  milk  ma}^  contain  many  millions  in  the  same  quantity.  In 
1906  the  milk  sold  in  Washington,  D.  C,  averaged  22,131,000  per 
cubic  centimeter,  and  the  year  following  there  were  11.270,000.  In 
Rochester,  and  many  other  cities,  100,000  is  regarded  as  the  limit  in 
milk  fit  for  human  food.  Milk  which  is  certified  by  milk  commissions 
ought  not  to  contain  more  than  10,000  per  cubic  centimeter,  although 
some  commissions  have  adopted  other  numbers  as  the  maximum  limit. 
So-called  inspected  milk  should  not  contain  over  100,000  per  cubic 
centimeter,  and  milk  containing  more  than  this  should  be  regarded  as 
unfit  for  human  consumption,  and  especially  so  for  infants  and  young 
children.  ]\lilk  containing  large  quantities  of  bactei-ia  must  of  neces- 
sity undergo  considerable  decomposition,  and  clinical  experience 
teaches  us  that  such  milk  is  unfit  to  feed  infants  and  may  produce 
gastro-intestinal  disease.  The  nature  of  the  bacteria  present  is  im- 
portant, as  disease-producing  germs  are  dangerous  to  the  public  health. 
Milk  which  contains  but  few  bacteria  will,  as  a  rule,  contain  no  disease- 
producing  bacteria,  or  but  very  few,  while  milk  with  very  high 
bacterial  counts  is  extremely  liable  to  contain  them.  Almost  all  of 
the  pathoiicnic  bacteria  grow  better  at  or  near  the  body  temperature, 
and  grow  slowly,  if  at  all,  in  milk  which  is  cold  enough  to  prevent  the 
rapid  growth  of  bacteria. 

Each  time  milk  is  handled  there  is  an  increase  in  the  number  of 
bacteria,  and  they  are  also  increased  in  separated  and  filtered  milk. 
Under  ordinary  circumstances  milk  drawn  from  the  udder  of  the  cow 
contains  bacteria  which,  with  reasonably  simple  precaution,  may  be 
easily  kept  under  5000  per  cubic  centimeter.  To  keep  these  from 
increasing,  the  milk  must  be  protected  from  further  contamination 
and  must  be  kept  cold.  The  increase  may  also  be  influenced  by  pas- 
teurizing and  sterilizing,  which  have  already  been  considered.  Milk 
ehilJed  to  15°  or  40°  F.  will  have  little  or  no  increase  in  the  number 
of  ordinary  bacteria,  and  there  is  not  much  growth  until  it  is  warmed 
to  70°  F. ;  after  that  conditions  are  more  favorable  to  bacterial  life, 
and  between  80°  F.  and  98°  F.  the  increase  is  enormous.  When  the 
temperature  reaches  over  100°  F.  the  bacteria  ordinarily  found  in 
milk  do  not  grow  well,  and  when  the  milk  is  heated  to  125°  F.  the 
eflfect  is  to  kill  some  of  the  germs,  and  an  exposure  of  ten  minutes  at 
160°  F.  will  kill  the  majority  of  milk  bacteria,  but  not  the  spores. 

The  source  of  the  bacteria  is  of  interest,  as  the  milk  as  formed  in 
the  mammary  gland  in  the  healthy  cow  is  free  from  germs.  Small 
wounds  of  the  udder  may  lead  to  bacterial  invasion  and  the  germs 


I 


ANIMAL  FOODS  103 

get  into  the  mouths  of  the  teats  and  so  into  the  milk  chamber,  so  that 
the  first  milk  drawn  should  be  rejected,  and  even  the  milk  drawn 
later  may  contain  some  bacteria  from  the  growth  of  them  having 
extended  up  the  milk  ducts.  The  milk  at  the  end  of  the  milking  is 
nearly  or  quite  sterile.  Inflammation  of  the  udder  and  mammary 
gland  may  lead  to  very  serious  infection  of  the  milk  by  disease-pro- 
ducing bacteria.  During  the  milking  the  contamination  is  often  sur- 
prisingly great.  The  number  of  bacteria  in  the  air  of  the  ordinary 
cow  barn  is  very  great,  and  if  the  hay  loft  is  above  it  and  the  hay  is 
thrown  down  just  previous  to  milking  the  air  may  be  clouded  with 
germs.  Particles  of  manure,  hairs,  and  other  foreign  material  may 
drop  into  the  milk,  and  the  milker's  hands  and  dust  from  his  clothing 
are  also  a  frequent  source  of  contamination.  The  bacteria  from  man 
are  more  dangerous  to  human  health  than  those  from  the  cow.  If 
the  milk  pails  and  other  receptacles  are  not  sterilized,  a  goodly  lot  of 
bacteria  will  be  found  in  the  milk  collected  in  the  seams,  and  the  cloth 
through  which  the  milk  is  strained  maj^  add  to  the  number  if  it  is  not 
sterile.  The  cooler,  the  cans,  and  the  milk  bottles,  unless  sterilized,  all 
add  their  quota  of  bacteria,  and  every  time  the  milk  is  handled  or 
opened  to  the  air  additional  contamination  takes  place.  The  sum 
total  of  all  these  may  be  very  great,  and  the  milk  may  start  on  its 
journey  with  more  bacteria  in  it  than  would  be  safe  for  infants  or 
invalids. 

Various  species  of  bacteria  may  be  found  in  the  milk  duets,  and 
these  differ  in  different  cows,  but  certain  species  of  streptococci  are 
most  often  present.  These  are  reasonably  constant,  and,  as  a  rule, 
do  not  apparently  produce  any  marked  changes  in  the  milk,  although 
at  times  they  are  evidently  the  cause  of  changes  to  an  alkaline  reac- 
tion. The  ({uestion  of  these  streptococci  and  milk  is  deserving  of 
further  study,  as  they  are  not  thoroughly  understood,  and  as  yet 
there  is  not  a  satisfactory  method  for  distinguishing  the  non-patho- 
genic from  the  pathogenic. 

Leukocytes  may  be  found  in  the  milk  of  healthy  cows,  but,  as  a  rule, 
they  are  more  numerous  in  the  milk  from  diseased  animals,  and,  if 
present  in  large  numbers,  a  special  examination  should  be  made  for 
garget  and  other  diseases.  Just  what  an  average  number  would  be 
cannot  at  this  time  be  definitely  stated,  but  the  milk  from  the  average 
herd  kept  under  favorable  conditions  will  contain  over  100,000  per 
cubic  centimeter.  In  diseases  of  the  udder  and  in  garget  the  number 
reaches  500.000  or  over,  and  may  extend  into  the  millions. 

The  Souring  of  Milk. — With  but  few  exceptions  milk  will  sour  in 
various  lengths  of  time,  and  it  may  be  regarded  as  a  normal  phe- 
nomenon. As  a  matter  of  fact,  milk  which  does  not  sour  under 
ordinary  conditions  should  be  regarded  with  suspicion  and  tested 
for  preservatives.  When  the  milk  reaches  a  certain  stage  of  acidity 
it  curdles.     Curdling  may  be  due  to  certain  yeasts  and  moulds,  and 


104  GLASSES  OF  FOOD 

may  be  produced  by  rennet,  but  by  far  the  most  frequent  cause  is  the 
lactic  acid  bacilli.  Over  a  hundred  different  bacteria  have  been  de- 
scribed as  causing  the  souring  of  milk,  but  for  the  most  part  many 
of  these  are  not  commonly  met  with,  and  many  of  the  others  belong 
to  one  or  two  groups.  By  far  the  most  common  of  these  is  what  is 
ordinarily  spoken  of  as  the  lactic  acid  bacillus,  which  does  not  produce 
gas,  and  which  grows  best  in  deep  vessels,  where  the  air  is  more  or 
less  excluded.  Under  favorable  conditions  these  bacilli  multiply 
rapidly,  and  the  acid  which  they  produce  unites  with  the  casein,  and, 
when  it  reaches  a  certain  percentage,  it  precipitates.  Heat  will  hasten 
this,  as  is  frequently  demonstrated  by  the  curdling  which  takes  place 
on  heating  or  adding  nearly  turned  milk  to  hot  tea  or  coffee.  Milk 
soured  by  the  lactic  acid  bacillus  has  a  firm  clot  with  a  little  whey  on 
top  and  is  free  from  gas.  When  the  curd  is  broken  up  by  shaking,  it 
separates  from  the  whey  and  sinks  to  the  bottom.  Such  milk  has  a 
pleasant  acid  taste  and  is  much  used  for  food,  either  as  clabber  or 
curds  and  whey  or  cottage  cheese.  Another  group  of  acid-producing 
bacteria  grow  best  in  milk  which  is  well  aerated,  as  that  in  shallow 
pans,  and  it  produces  gas,  so  that  the  curd  is  broken  up  and  contains 
gas  bubbles.  These  bacteria  are  a  source  of  trouble  to  manufacturers 
of  cheese.  The  changes  produced  in  milk  by  the  first  group  of  lactic 
acid  bacilli  are  of  value  in  the  manufacture  of  butter  and  cheese,  but 
are  unfavorable  to  the  average  milk  dealer  and  consumer,  and  much 
of  the  care  devoted  to  milk  is  directed  against  the  growth  of  these 
organisms. 

There  is  a  popular  belief  that  a  thunder  shower  will  sour  milk. 
The  fact  seems  to  be  pretty  well  demonstrated  that  the  climatic  con- 
ditions which  produce  thunder  showers  are  those  favorable  to  the 
growth  of  the  bacteria  which  sour  milk ;  and  during  the  hot  weather 
milk  frequently  sours  apart  from  thunder  storms,  and  also  that  milk 
cooled  immediately  after  milking  and  kept  properly  cooled  will  not 
sour  during  a  thunder  storm. 

Milk  Production. — The  production  of  milk  which  will  keep  a 
reasonable  length  of  time  and  is  free  from  objectionable  features  is 
a  comparatively  simple  matter,  but  it  requires  care  and  constant 
supervision,  and  is  best  undertaken  by  persons  trained  in  dairying. 
The  first  consideration  is  the  cow  herself,  and,  to  produce  good,  pure 
milk,  the  cow  must  be  healthy  and  must  be  kept  clean.  Sick  cattle 
should  be  separated  from  the  herd,  and  if  a  herd  is  to  be  kept  free 
from  tuberculosis,  no  cow  should  be  added  to  it  without  first  having 
been  tested  by  tuberculin,  and  the  entire  herd  should  be  tested  from 
time  to  time.  The  cow  should  be  groomed  regularly,  the  same  as  a 
horse,  the  oftener  the  better,  and  this  reduces  the  bacterial  contamina- 
tion of  milk  very  materially.  Some  dairymen  cut  off  the  longer  hairs 
about  the  flanks  and  tail  to  lessen  the  danger  of  having  them  soiled 
with  feces.     The  grooming  should  be  done  before  milking,  and  the 


ANIMAL  FOODS  105 

COW  should  not  be  allowed  to  lie  down  until  she  has  been  milked.  The 
stables  should  be  clean,  light,  and  airy,  and  a  special  milking  room  is 
desirable  unless  the  barn  is  of  good  construction  and  of  sufficient 
size.  Anything  which  stirs  up  dust  should  be  avoided.  The  barn- 
yard should  be  kept  clean  and  drained.  The  employees  should  be 
healthy  and  clean,  and  the  hands  should  be  thoroughly  scrubbed  before 
milking.  ]Many  large  dairy  farms  supply  sterile  suits  to  their  em- 
ployees to  be  worn  at  milking  time.  No  one  who  has,  or  who  has 
recently  had,  or  who  is  associated  in  any  way  with  any  contagious 
disease,  should  be  allowed  to  have  anything  whatever  to  do  with  milk 
production. 

The  milk  pails  and  all  milk  receptacles  should  be  kept  clean  and 
scalded  as  thoroughly  as  possible,  and  sterilizing  with  live  steam 
should  be  done  wherever  practicable.  The  water  supply  of  the  dairy 
is  of  great  importance,  and  many  large  dairy  companies  now  insist 
upon  special  examination  of  the  water  and  water-supply  before  re- 
ceiving milk  from  farms. 

Specially  constructed  milk  pails,  which,  in  a  large  measure,  prevent 
the  dirt  and  dust  from  falling  into  the  milk,  are  sometimes  used,  and 
assist  in  reducing  the  contamination  of  the  milk. 

Milk  Standards. — The  Committee  appointed  by  the  New  York  Milk 
Committee  suggests  the  following  standards  for  large  cities.  Smaller 
towns  may  modify  the  standards  according  to  the  length  of  time  the 
milk  is  kept  and  the  distance  it  is  transported  before  delivery. 

Grade  A. 

Raw  milk. — Milk  of  this  class  shall  come  from  cows  free  from  disease  as  deter- 
mined by  tuberculin  tests  and  physical  examinations  by  a  qualified  veterinarian, 
and  shall  be  produced  and  handled  by  employees  free  from  disease  as  determined 
by  medical  inspection  of  a  qualified  physician,  imder  sanitary  conditions,  such  that 
the  bacterial  coimt  shall  not  exceed  10,000  per  cubic  centimeter  at  the  time  of 
delivery  to  the  consumer.  It  is  recommended  that  dairies  from  which  this  supply 
is  obtained  shall  score  at  least  80  on  the  United  States  Bureau  of  Animal  In- 
dustry score  card. 

Pasteurized  milk. — Milk  of  this  class  shall  come  from  cows  free  from  disease  as 
determined  by  physical  examinations  by  a  qualified  veterinarian,  and  shall  be 
produced  and  handled  imder  sanitary  conditions,  such  that  the  bacteria  count 
at  no  time  exceeds  200,000  per  cubic  centimeter.  All  milk  of  this  class  shall 
be  pasteurized  under  official  supervision,  and  the  bacteria  count  shall  not  exceed 
10,000  per  cubic  centimeter  at  the  time  of  delivery  to  the  consumer.  It  is 
recommended  that  dairies  from  which  this  supply  is  obtained  shall  score  at  least 
65  on  the  United  States  Bureau  of  Animal  Industry  score  card. 

Grade  B. 

Milk  of  this  class  shall  come  from  cows  free  from  disease  as  determined  by 
physical  examinations,  of  which  one  each  year  shall  be  by  a  qualified  veterinarian, 
and  shall  be  produced  and  handled  under  sanitary  conditions,  such  that  the 
bacteria  count  at  no  time  exceeds  1,000,000  per  cubic  centimeter.  All  milk  of  this 
class  shall  be  pasteurized  under  official  super\asion,  and  the  bacterial  coimt 
shall  not  exceed  50,000  per  cubic  centimeter  when  delivered  to  the  consumer. 

It  is  recommended  that  dairies  producing  grade  B  milk  should  be  scored, 
and  that  the  health  departments  or  the  controlling  departments,  whatever  they 
may  be,  strive  to  bring  these  sources  up  as  rapidly  as  possible. 


106  CLAHiiEii  OF  FOOD 

Grade  C. 

Milk  of  this  class  shall  come  from  cows  free  from  disease,  as  determined  by 
physical  examinations,  and  shall  include  all  milk  that  is  produced  under  con- 
ditions such  that  the  bacterial  count  is  in  excess  of  1,000,000  per  cubic  centimeter. 

All  milk  of  this  class  shall  be  pasteurized,  or  heated  to  a  higher  temperature, 
and  shall  contain  less  than  50,000  bacteria  per  cubic  centimeter  when  delivered 
to  the  consumer. 

Whenever  any  large  city  or  community  finds  it  necessary,  on  account  of  the 
length  of  haul  or  other  peculiar  conditions,  to  allow  the  sale  of  grade  C  milk,  its 
sale  shall  be  surrounded  by  safeguards  such  as  to  insure  the  restriction  of  its  use 
to  cooking  and  manufacturing  purposes. 

The  Transportation  and  Delivery  of  Milk. — This  cannot  be  fully 
considered  here,  but  it  maj-  be  stated  that  the  milk  should  be  trans- 
ported in  sterile  cans  or  bottles,  that  the  pouring  of  milk  from  one 
can  to  another  or  to  bottles  should  only  be  allowed  in  a  room  provided 
especially  for  that  purpose,  free  from  dust  and  other  source  of 
contamination.  The  milk  should  be  kept  cold  the  entire  time  until 
it  reaches  the  consumer,  and  by  him  until  used.  The  selling  of  milk 
from  open  cans  in  grocery  and  provision  shops  should  be  prohibited. 
The  safest  method  of  marketing  milk  is  in  sealed  bottles,  and,  unless 
some  other  solution  of  the  problem  offers,  this  should  be  the  only 
way.  Selling  from  cans,  the  way  it  is  done  in  the  United  States, 
is  open  to  a  number  of  objections,  but  the  public  has  not  been  educated 
to  demand  pure  bottled  milk,  although  much  has  been  done  in  this 
direction. 

The  Handling  and  Care  of  Milk. — As  we  have  seen,  the  produc- 
tion of  milk  reasonably  free  from  bacteria  is  a  question  of  cleanliness, 
and  the  question  of  handling  it  is  reduced  to  cleanliness  of  utensils, 
protection  of  the  milk  from  contamination  bj-  dust  and  dirt,  and 
keeping  it  cool.  The  milk  should  be  cooled  immediately  after  milk- 
ing, and  this  is  most  conveniently  accomplished  by  using  a  milk  cooler, 
of  which  there  are  many  different  models,  using  cold  water,  and  it 
should  be  kept  cold  until  used.  Various  devices  for  keeping  milk  by 
heating  it  to  over  110°  F.  have  been  advised,  but  while  most  bacteria 
will  not  grow  at  this  temperature,  some  undoubtedly'  do,  and  having 
seen  severe  diarrheas  caused  in  infants  by  keeping  milk  warm  at 
night,  we  advise  against  this  practice  in  the  present  state  of  our 
knowledge  of  bacteria  growing  at  high  temperatures. 

The  Adulteration  of  Milk. — The  most  frequent  adulteration  of 
milk  consists  in  removing  part  of  the  cream  and  adding  water.  In 
other  instances  good  milk  and  skim  milk  are  mixed  together.  In  both 
instances  the  consumer  is  robbed  by  paying  for  an  article  of  food 
which  does  not  have  the  nutritive  value  it  is  commonly  supposed  to 
possess.  The  addition  of  water  brings  the  added  danger  of  con- 
taminating the  milk,  as  a  milk  dealer  sufficiently  unscrupulous  to  add 
water  to  his  milk  would  be  apt  to  disregard  the  character  of  water 
used,  and,  as  a  matter  of  fact,  a  number  of  typhoid  epidemics  have 


AMMAL   FOODS  107 

been  caused  in  this  waj'.  I\lilk  is  artiHcially  colored,  but  this  practice 
is  not  as  common  as  is  poi)uIarly  supposed.  Almost  all  communities 
have  laws  forbidding  the  adulteration  of  milk  in  this  way. 

The  Use  of  Preservatives. — Chemical  preservatives  are  frequently 
added  to  milk  to  prevent  the  growth  of  bacteria,  and  it  is  frequently 
done  after  the  milk  is  partially  spoiled.  The  most  commonly  used 
articles  are  formaldehyd,  boric  acid,  borax,  salicylic  acid,  and  benzoic 
acid.  Only  small  amoiuits  are  needed  to  check  the  growth  of  bacteria, 
but  the  unscrupulous  dealer  usually  adds  a  great  deal.  Milk  which 
does  not  sour  in  a  reasonable  length  of  time  under  favorable  condi- 
tions for  souring  should  be  tested  for  preservatives.  The  use  of  all 
such  preservatives  should  be  prohibited  by  law.  The  so-called  Bud- 
deized  milk  has  had  hydrogen  peroxid  added  to  it,  which  sterilizes 
it,  and  the  peroxid  is  gradually  decomposed  into  oxygen  and  water. 
This  process  is  not  to  be  commended. 

The  Examination  of  Milk. — The  milk  should  be  thoroughly  mixed 
so  as  to  obtain  a  fair  sample,  but  if  the  fat  separates  in  small  lumps 
of  butter,  another  sample  should  be  secured.  Milk  should  adhere 
slightly  to  the  sides  of  the  glass  from  which  it  is  poured,  and  not  run 
off  like  water. 

Fat  Tests. — The  Babcock  test  is  the  best  method,  but  requires  the 
use  of  a  centrifugal  machine;  small  ones,  however,  may  be  obtained 
for  office  use.  The  amount  of  fat  in  the  milk  may  be  definitely  de- 
termined in  ten  or  fifteen  minutes  by  using  this  test,  which  is  made 
by  putting  a  definite  amount  of  milk  or  cream  in  a  special  graduated 
bottle,  adding  sulphuric  acid,  and  shaking  the  mixture  until  it  be- 
comes dark  in  color,  then  placing  the  bottle  in  a  centrifugal  machine 
and  running  it  until  the  fat  is  entirely  separated.  The  exact  per- 
centage can  be  read  ofit'  after  adding  sufficient  warm  water  to  bring 
the  fat  up  to  the  graduation  on  the  bottle.  A  simple  method,  but 
not  a  very  accurate  one,  is  to  use  a  creamometer,  which  is  a  tall, 
graduated  glass  cylinder.  This  is  filled  with  milk  and  allowed  to 
stand  for  about  twenty-four  hours.  The  process  may  be  hastened  by 
heating  to  100°  F.  and  then  placing  the  creamometer  in  cold  water. 
Another  method  is  to  fill  the  creamometer  half  full  of  milk  and  then 
add  warm  water.     The  reading  will  in  this  case  have  to  be  doubled. 

The  Specific  Gravity. — This  is  best  taken  by  the  Quevenne  lacto- 
meter, which  has  a  thermometer  enclosed  in  it  which  shows  both  the 
specific  gravity  and  temperature  of  the  milk.  The  milk,  to  get  ac- 
curate and  uniform  results,  is  tested  at  60°  F.  The  specific  gravity 
of  milk  varies  between  1.029  and  1.033,  and  sometimes  there  are  great 
variations.  The  specific  gravity  may  be  increased  if  the  cream  is 
removed,  and  if  water  is  added  the  specific  gravity  is  decreased.  A 
favorite  method  of  adulterating  milk  is  to  remove  part  of  the  cream 
and  then  add  sufficient  water  to  make  the  specific  gravity  normal. 


108  CLASSES  OF  FOOD 

The  lactometer  shows  only  the  specific  gravity  of  the  milk,  and  while 
sometimes  adulteration  may  be  detected  by  it,  it  is  not  a  certain 
test. 

Estimation  of  Protein. — Boggs  ^  has  suggested  the  following  test : 

Use  phosphotungstic  acid,  25  grams,  and  distilled  water  125  c.c. ; 
after  thorough  solution  is  obtained  there  is  added  hydrochloric  acid 
(cone),  25  c.c,  diluted  with  distilled  water,  100  c.c.  This  yields  250 
c.c.  of  a  10  per  cent,  solution  of  phosphotungstic  acid  in  about  3  per 
cent,  hydrochloric  acid.  The  solution  is  quite  stable  if  kept  in  a  dark 
bottle  and  gives  satisfactory  results  after  months  of  standing.  It  is 
desirable  that  the  components  be  mixed  as  indicated,  i.  e.,  the  well 
diluted  hydrochloric  acid  added  after  solution  of  the  phosphotungstic 
acid,  in  order  to  avoid  precipitation. 

The  sample  of  milk  to  be  tested  is  diluted  with  water,  using  standard 
pipets  and  flasks  to  secure  maximum  accuracy.  Esbaeh's  tables  of 
standard  patterns  reading  from  1  to  7  grams  per  liter  are  more  satis- 
factory. 

The  diluted  milk  is  poured  into  the  tube  to  the  mark  U,  being  care- 
ful to  read  from  the  bottom  of  the  meniscus.  The  phosphotungstic 
acid  solution  is  added  to  the  mark  R,  the  tube  corked,  and  slowly 
inverted  twelve  times  to  secure  thorough  mixing,  care  being  had  to 
avoid  shaking  roughly  and  thus  mixing  air  in  the  fluid.  The  tube  is 
then  placed  in  a  rack  for  twenty-four  hours,  and  the  percentage  read 
off  at  the  level  of  the  top  of  the  precipitate.  Fractions  of  percentage 
between  the  graduations  are  readily  judged  by  the  eye.  At  dilutions 
of  one  part  in  ten,  percentage  of  protein  is  read  directly  from  the 
scale,  while  if  the  solution  be  one  in  twenty,  we  multiply  the  reading  by 
two,  if  one  in  five,  we  divide  by  two. 

The  optimum  dilution  for  human  milk  is  1  in  10.  That  for  cows' 
milk,  1  in  20.  If  the  protein  content  be  found  extremely  low  we  may 
use  1  in  5  for  human  milk  and  1  in  10  for  cows'  milk. 

As  temperature  has  a  definite  influence  on  the  volume  of  the  pre- 
cipitate, it  is  desirable  that  the  tubes  be  not  exposed  to  extremes, 
although  the  ditfereuces  noted  in  this  precipitate  were  not  nearly  so 
great  as  when  Esbaeh's  solution  was  used. 

No  considerable  variation  was  found  in  volume  of  precipitates,  with 
temperatures  ranging  becween  15°-25°  C.  (59°-77°  F.),  while  in  the 
thermostat  at  37°  C.  all  floated,  and  in  the  ice-box  at  5°  C.  (41°  F.) 
all  read  appreciablj^  higher  than  at  room  temperatures,  averaging  20° 
C.   (68°  F.). 

The  minimum  volume  of  the  precipitate  is  reached  in  twenty-four 
hours. 

Tests. — The  Acid  Test. — From  the  time  of  milking  until  it  sours 
the  acidity  of  milk  is  constantly  increasing,  and  while  no  definite 
standard  has  been  adopted  as  the  maximum  acidity  which  should  be 

1  Bulletin  of  the  Johns  Hopkins  Hospital,  October,  1906. 


ANIMAL  FOODS  109 

accepted  by  a  consumer,  it  furnishes  a  simple  means  of  testing  milk. 
Farrington,  of  Wisconsin,  has  had  tablets  made  of  a  definite  quantity 
of  some  alkali,  such  as  caustic  potash  or  soda,  containing  a  little 
phenolphthalein,  which  is  colorless  in  acid  solutions  and  pink  in  alka- 
line solutions.  The  tablets  are  made  of  such  strength  that  if  two  of 
them  turn  one  ounce  of  milk  pink,  such  milk,  with  proper  care,  should 
keep  a  reasonable  length  of  time. 

Hydrogen  peroxid  may  be  detected  in  milk  by  the  use  of  a  solution 
of  titannie  acid  (titannium  hydrate)  dissolved  in  sulphuric  acid. 
This  is  added  to  a  few  cubic  centimeters  of  milk,  and  if  the  peroxid  is 
present  coloration  appears,  but  varies  between  a  light  yellow  and  a 
deep  orange,  according  to  the  amount  of  peroxid  present.  A  some- 
what similar  reaction  takes  place  from  milk  containing  salicylic  acid. 

Formaldehyd  is  best  tested  by  using  either  Hehner's  or  Leach's  test. 
They  are  based  on  the  appearance  of  a  violet  color  when  concentrated 
sulphuric  acid  or  hydrochloric  acid  containing  a  trace  of  iron  is  added 
to  the  milk. 

Hehiier's  Test. — To  a  few  cubic  centimeters  of  concentrated  sul- 
phuric acid,  to  which  a  trace  of  some  ferric  salt  has  been  added,  add 
the  milk  to  be  tested  so  as  to  form  a  distinct  layer  on  top  of  the  acid 
and  allow  to  stand.  If  formaldehyd  be  present,  even  one  part  to  a 
million  of  milk,  a  violet  coloration  will  take  place  at  the  junction  of 
the  two  liquids. 

Leach's  Method. — Dilute  the  milk  with  an  equal  volume  of  water 
and  add  for  each  cubic  centimeter  of  the  diluted  milk  1  c.c.  of  con- 
centrated hydrochloric  acid  containing  1  c.c.  of  10  per  cent,  ferric 
chlorid  solution  to  each  500  c.c.  of  acid.  The  mixture  is  heated  in  a 
casserole  over  the  bare  flame  to  80°  or  90°  C,  rotating  to  break  the 
curd  which  forms.  If  formaldehyd  be  present,  a  violet  color  will 
appear. 

Detection  of  heated  milk. — Storch's  method. — Five  cubic  centimeters 
of  milk  are  poured  into  a  test  tube;  a  drop  of  weak  solution  of 
hydrogen  dioxide  (about  0.2  per  cent.)  which  contains  about  0.1  per 
cent,  sulphuric  acid,  is  added,  and  two  drops  of  a  2  per  cent,  solution 
of  paraphenylendiamin  (solution  should  be  renewed  quite  often),  then 
the  fluid  is  shaken.  If  the  milk  or  the  cream  becomes,  at  once,  indigo 
blue,  or  the  whey  violet  or  reddish  brown,  then  this  has  not  been 
heated  or,  at  all  events,  it  has  not  been  heated  higher  than  78°  C. 
(172.5°  F.)  ;  if  the  milk  becomes  a  light  bluish  gray  immediately  or 
in  the  course  of  half  a  minute,  then  it  has  been  heated  to  79°  to  80° 
C.  (174.2°  to  176°  F.),  If  the  color  remains  white,  the  milk  has  been 
heated  at  least  to  80°  C.  (176°F.).  In  the  examination  of  sour  milk 
or  sour  buttermilk,  lime  water  must  be  added,  as  the  color  reaction 
is  not  shown  in  acid  solution. 

Arnold's  guaiac  method. — A  little  milk  is  poured  into  a  test  tube 
and  a  little  tincture  of  guaiac  is  added,  drop  by  drop.     If  the  milk 


110 


CLASSES  OF  FOOD 


has  not  been  heated  to  80^  C.  (176°  F.)  a  blue  zone  is  formed  between 
the  two  fluids:  heated  milk  gives  no  reaction,  but  remains  white. 
The  guaiac  tincture  should  not  be  used  perfectly  fresh,  but  should  have 
stood  a  few  days  and  its  potency  have  been  determined.  Thereafter  it 
can  be  used  indefinitely.  These  tests  for  heated  milk  are  only  active 
in  the  case  of  milks  which  have  been  heated  to  176°  F.  or  80'  C. 
(Jensen's  j\lilk  Hygiene,  Pearson's  translation,  p.  192.) 

Microscopic  test  for  heated  {pasteurized) milk — Fj-ost  and  Ravenel. 
— About  15  c.c.  of  milk  are  centrifuged  for  five  minutes,  or  long 
enough  to  throw  down  the  leukocytes.  The  cream  layer  is  then 
completely  removed  with  absorbent  cotton  and  the  milk  drawn  off  with 
a  pipette,  or  a  fine-pointed  tube  attached  to  a  Chapman  air  pump. 
Only  about  2  mm.  of  milk  are  left  above  the  sediment  which  is  in  the 
bottom  of  the  sedimentation  tube. 

The  stain,  which  is  an  aciueous  solution  of  safranin  0,  soluble  in 
water,  is  then  added  very  slowly  from  an  opsonizing  pipette.  The 
important  thing  is  to  mix  stain  and  milk  so  slowly  that  clotting  does 
not  take  place.  The  stain  is  added  until  a  deep  opaciue  rose  color  is 
obtained.  After  standing  three  minutes,  by  means  of  the  opsonizing 
pipette,  which  has  been  washed  out  in  hot  water,  the  stained  sediment 
is  then  transferred  to  slides.  A  small  drop  is  placed  at  the  end  of 
each  of  several  slides  and  spread  by  means  of  a  glass  spreader,  as  in 
Wright's  method  for  opsonic  index  determinations. 

In  an  unheated  milk  the  polymorphonuclear  leukocytes  have  their 
protoplasm  slightly  tinged  or  are  unstained. 

In  heated  milk  the  polymorphonuclear  leukocytes  have  their  nuclei 
stained.  In  milk  heated  to  63°  C.  or  above,  practically  all  of  the 
leukocytes  have  their  nuclei  definitely  stained.  When  milk  is  heated 
at  a  lower  temperature  the  nuclei  are  not  all  stained  above  60°  C. 
The  majority,  however,  are  stained. 

Cream. — When  milk  is  allowed  to  stand  undisturbed,  the  fat  drop- 
lets, being  of  lower  specific  gravity  than  the  remainder  of  the  milk, 
gradually  rise  to  the  top,  and  the  longer  the  milk  stands,  up  to  a 
certain  limit,  the  more  cream  will  be  found.     As  far  as  the  composition 


Cream. 

Whole  milk 

I. 

II. 

III. 

IV. 

V. 

Fat 

4.00 

8.00 

12.00 

16.00 

20.00 

40.00 

Siif^ar 

4.50 

4.50 

4.20 

4.05 

3.90 

3.00 

Protein     .    .    . 

3.50 

3.40 

3.30 

3.20 

3.05 

2.20 

8alts     .... 

0.75 

0.70 

0.65 

0.60 

0.55 

0.45 

of  cream  goes,  it  is  most  easily  remembered  as  regarding  it  as  milk 
containing  a  large  amount  of  fat.  The  percentages  of  the  other  ingre- 
dients being  for  all  practical  purposes  about  the  same  as  in  milk  or  a 


ANIMAL  FOODS 


111 


little  lower.  Creams  are  usually  spoken  of  with  reference  to  the 
amount  of  fat  which  they  contain,  so  one  speaks  of  a  16  per  cent, 
cream,  20  per  cent,  cream,  etc.  The  composition  of  these  is  given  in 
the  table  from  Holt  on  page  110. 

The  cream  which  rises  on  average  milk  after  twenty-four  hours 
usually  contains  about  16  per  cent.  fat.  and  is  spoken  of  as  gravity 
cream.  Some  gravity  cream  maj-  contain  as  much  as  18  or  20  per 
cent.  fat.  The  richer  creams  are  obtained  by  centrifugalizing  the 
milk.  This  has  the  advantage  that  cream  may  be  put  on  the  market 
a  short  time  after  milking,  but  it  has  the  disadvantage  that  the  fat 
globules  may  be  broken  up  and  fused,  so  that  a  thin  layer  of  fat 
may  be  found  on  top  of  the  bottle. 

The  upper  part  of  the  cream,  after  standing,  is  richer  in  fat  than 
the  lower  part,  and  this  is  true  of  the  milk  taken  as  a  whole.  The 
variations  are  well  shown  in  the  following  table  from  Holt : 


Percentage  of  fat  iu— 

After  four 
hours. 

After  eight 
hours. 

Over  uight. 

Upper  4  oz 

Second  4  oz 

Third  4  oz 

Fourth  4  oz 

Fifth  4  oz 

20.50 
6.00 
1.50 
1.20 
1.00 

21.25 
6.50 
1.40 
1.00 
1.00 

22.00 
6.50 
1.00 
0.30 
0.20 

The  fat  droplets  in  cream  vary  in  size  in  the  ditt'erent  varieties  of 
cows.  In  the  Alderneys  and  Guernseys  the  droplets  are  larger,  less 
uniform  in  size,  and  more  numerous  than  in  milk  from  the  ordinary 
milch  cow.  The  small  uniform  fat  droplets  of  milk  from  average 
herds  is  to  be  preferred  in  infant  feeding.  Ordinarily,  if  average 
milk  has  stood  until  the  cream  has  risen,  the  upper  third  of  the  milk 
in  the  bottle  will  contain  about  10  per  cent,  fat  and  the  upper  half 
about  7  per  cent.  fat.  Cream  rises  best  on  milk  that  has  been  cooled 
quickly  after  milking  and  which  has  been  handled  but  little.  Milk 
which  has  been  shaken  up  frequently  and  frozen  and  thawed  does 
not  yield  as  much  cream,  nor  as  ({uickly. 

Skim  Milk. — This  is  the  residue  remaining  after  the  removal  of 
cream  from  ordinary  milk,  and  differs  from  it  in  having  most  of  the 
fat  removed,  and  is  slightly  richer  in  casein  and  milk-sugar.  It  is 
easily  digested  by  most  people  and  is  frequently  sold  as  wdiole  milk. 
The  average  composition  of  skim  milk,  according  to  Letheby,  is  as 
follows  • 

Water     88.0 

Protein     4  0 

Fats    1.8 

Milk-sugar     5.4 

Salts     0.8 

Devonshire  cream  is  more  or  less  solid  clotted  cream,  obtained  by 


112  CLASSES  OF  FOOD 

skimming  milk  after  it  has  been  heated  slowly  to  not  over  150°  F.  It 
is  very  extensively  used  in  Devonshire,  and  is  very  nutritious,  but  less 
digestible  than  ordinary  cream. 

Butter. — Butter  is  made  from  milk  by  churning,  which  causes  the 
fat  globules  in  the  milk  to  coalesce,  thus  forming  a  .solid  mass.  Occa- 
sionally butter  is  made  from  other  milk  than  that  of  the  cow.  Butter 
is  made  most  rapidly  from  cream  that  has  been  ripened  from  twelve 
to  twenty-four  hours,  and  churned  at  a  temperature  between  65°  and 
70°  F.  In  this  way  butter  may  be  separated  in  from  twelve  to  thirty 
minutes.  The  process  of  ripening  has  been  carefully  studied,  and  it 
has  been  found  that  the  bacterial  flora  of  a  creamery  varies  with  the 
season  of  the  year,  and  also  the  taste  and  odor  of  the  butter  varies 
correspondingly.  Instead  of  depending  on  chance  bacterial  inva- 
sions of  the  milk,  which  may  produce  at  times  unpleasant  flavors,  it  is 
the  practice  in  many  creameries  to  inoculate  the  milk  with  a  culture 
of  bacteria  known  to  impart  a  desirable  flavor  to  the  butter.  In  this 
way  a  saving  is  brought  about  and  the  quality  of  the  butter 
improved. 

When  butter  is  kept  too  long  it  becomes  rancid,  and  this  is  due 
chiefly  to  the  fermentation  of  the  small  amount  of  casein  remaining 
in  the  butter  liberating  fatty  acids.  To  avoid  this  the  butter  should 
be  kept  cold.  Salting  is  largely  used  for  preventing  this  fermenta- 
tion. The  amount  used  should  not  exceed  2  per  cent.,  and  it  should 
be  worked  into  the  butter  so  that  no  undissolved  particles  remain. 
The  unsalted  or  sweet  butter  is  largely  used  in  Europe,  but  there  is 
not  a  great  demand  for  it  in  the  United  States.  Butter  is  often 
colored,  largely  because  the  public  still  like  a  dark,  yellow  color. 
Annatto  is  largely  used  for  this  purpose.  The  United  States  standard 
for  butter  is  that  it  shall  not  contain  more  than  16  per  cent,  of  water, 
nor  less  than  82.5  per  cent,  of  butter  fat.  Approximately  butter  may 
be  said  to  consist  of — 

Fat 90.0 

Water     10.0 

Sugar  or  milk 0.5 

Casein     0.5 

On  account  of  the  ease  with  which  fresh  butter  is  digested,  it  is 
one  of  the  most  valuable  of  the  fatty  foods. 

Renovated  Butter. — This  is  made  from  butter  which  has  become 
rancid,  by  melting  and  washing  with  water.  This  has  no  flavor,  and 
so  it  is  given  a  butter  flavor  by  mixing  with  a  certain  amount  of  sour 
cream. 

Testing  Renovated  Butter  and  Oleomargarin. — Kenovated  butter 
and  oleomargin  may  be  distinguished  from  ordinary  butter  by  boiling 
a  small  amount  in  a  small  pan  or  tablespoon.  It  should  be  melted 
slowly,  and  stirred  with  a  wooden  splinter  or  match  stick  several 
times  during  the  boiling.     Genuine  butter  boils  with  little  noise  and 


AMMIL  FOODH  113 

produces  au  abundance  of  foam,  while  renovated  butter  and  oleo- 
margarin  boil  noisily  and  sputter  like  a  mixture  of  grease  and  water, 
and  produce  less  foam. 

The  Waterhouse  Test. — Oleomargarin  may  also  be  distinguished 
from  butter  and  renovated  butter  by  the  Waterhouse  test. 

■  Sweet  skimmed  milk  is  used,  filling  a  half-pint  cup  half  full,  then 
heat  this  nearly  to  boiling,  and  add  a  slightly  rounded  teaspoonful  of 
the  material  to  be  tested.  Stir  with  a  wooden  rod  and  continue  heat- 
ing until  the  milk  boils  up,  then  remove  from  the  heat  and  cool  in  a 
pan  containing  rather  large  fragments  of  ice  and  a  little  water. 
When  the  cup  is  placed  in  the  pan  the  water  should  reach  on  the 
outside  of  the  cup  to  one-fourth  of  the  height  of  the  milk  within. 
The  contents  of  the  cup  should  be  stirred  rather  rapidly  and  con- 
tinuously, and  about  once  a  minute  the  cup  should  be  moved  about  in 
the  ice  so  as  to  facilitate  cooling.  If  the  sample  is  oleomargarin  the 
fat  gathers  into  one  soft  lump,  and  if  it  is  butter  the  fat  becomes 
granulated  and  cannot  be  collected.  AVhen  the  test  is  properly  carried 
out  the  distinction  is  very  marked. 

Buttermilk. — The  residue  left  in  the  churn  is  called  buttermilk, 
and  is  largely  used  as  a  beverage,  as  it  is  nutritious  and  easily 
digested.  It  contains  the  casein  of  the  milk  in  a  finely  coagulated 
form,  has  a  pleasant  acid  taste,  and  contains  lactic  acid  bacilli.  The 
buttermilk  left  after  churning  fresh  milk  has  approximately  the  same 
composition  as  skimmed  milk.  Buttermilk  from  ripened  cream  varies 
somewhat.     Wiley  gives  the  following  analyses : 

From  sweet  From  sour 

cream.  cream. 

Water    89.74  90.93 

Fat     1.21  0.31 

Milk-sugar    4.98  4.58 

Protein    3.28  3.37 

Ash     0.79  0.81 

Acidity    0.80 

A  preparation  similar  to  buttermilk  is  also  frequently  made  from 
the  whole  milk  by  inoculating  with  lactic  acid  bacilli.  This  is  a 
pleasant,  nutritious  drink,  much  in  vogue  at  the  present  time.  It  is 
useful  in  feeding  invalids,  especially  those  with  certain  forms  of  gas- 
tric and  intestinal  disorders,  and  in  feeding  infants.  Compressed 
tablets  of  lactic  acid  bacilli  may  be  obtained  on  the  market,  and,  while 
less  satisfactory  than  the  fresh  cultures,  may  be  used  where  the  latter 
are  unobtainable.  Conserved  buttermilk,  made  somewhat  after  the 
manner  of  condensed  milk,  is  also  used,  especially  for  infant  feeding. 
Dried  buttermilk  has  also  been  placed  on  the  m.arket. 

Bonnyclabber. — This  is  soured  milk  in  which  the  curd  and  whey 
are  served  in  the  same  dish,  and  usually  eaten  with  the  addition  of 
sugar.  Curd  and  whey  or  junket  is  milk  where  the  coagulation  has 
been  brought  about  by  rennet.  In  many  instances  the  whey  is 
removed  and  used  as  a  food  for  invalids  and  infants. 


114  CLAiiHES  OF  FOOD 

Cheese. — Chf^ese  is  made  of  the  curd  aud  a  certain  proportion  of 
fat  of  milk,  and  varies  in  composition  and  consistence  according  to  the 
method  employed  in  the  manufacture.  The  simplest  form  of  cheese 
is  the  so-called  cottage  cheese,  in  which  the  curd  is  separated  from 
the  whey  aud  eaten  a  short  time  after  it  is  made.  The  other  cheeses 
are  kept  a  certain  length  of  time  to  insure  ripening.  Sometimes  the 
coagulation  is  produced  by  rennet  and  sometimes  by  lactic  acid,  while 
various  forms  of  bacteria  growing  in  the  cheese  and  also  certain 
moulds  impart  to  the  different  varieties  their  peculiar  flavors.  Some 
cheeses  are  hard  and  some  are  soft,  the  difference  being  due  to  the 
amount  of  pressure  used  in  hardening  them.  As  a  rule,  the  harder 
cheeses  keep  very  much  longer  than  the  softer  ones.  The  average 
composition  of  cheese,  as  shown  by  Parks,  is  as  follows : 

Water 36.0 

Protein     31.0 

Fats    28.5 

Salts   4.5 

Cheese  is  a  nutritious  and  agreeable  food,  but  some  people  find  it 
difficult  of  digestion.  As  a  rule,  the  harder  the  cheese,  the  more 
indigestible  it  is.  Like  milk,  cheese  may  contain  certain  poisonous 
substances  due  to  bacterial  action,  and  severe  poisoning  may  follow 
the  eating  of  such  cheese.  In  recent  years  the  study  of  the  manufac- 
ture of  various  cheeses  has  been  carried  on,  so  that  Roquefort  and 
Camembert  and  other  foreign  cheeses  are  imitated  with  considerable 
success  in  the  United  States.  The  artificial  coloring  of  cheese  is  still 
very  common  in  the  United  States,  and  should  be  prohibited  by  law. 
Cheese  is  sometimes  adulterated,  and  a  cheap  cheese,  known  as  filled 
cheese,  is  made  by  adding  neutral  lard  to  the  milk  to  replace  the  butter 
fat.  In  the  United  States  such  cheese  is  taxed  and  must  be  branded 
as  such. 

Condensed  Milk. — This  is  manufactured  by  heating  the  milk  to 
212°  F.  to  sterilize  it  and  then  evaporating  in  a  vacuum  until  it 
becomes  thick  and  jelly-like.  To  this  considerable  amounts  of  cane- 
sugar  are  added.  In  some  cities  fresh  condensed  milk  may  be  obtained 
which  has  not  had  sugar  added  to  it.  The  composition  of  condensed 
milk  is  as  follows: 

Total  solids  Protein  Fat  Milk-sugar  Cane-sugar 

per  cent.  per  cent.  per  cent.  per  cent.         per  cent. 
Unsweetened    condensed    milk.     40                     12                     12  16  0 

Sweetened    condensed    milk....      80  12  12  16  40 

The  Borden  Company  have  furnished  the  following  analyses : 

Eagle  Brand  Condensed  Milk. 

Fat    9.82 

Milk-sugar     12.49 

Protein     8.80 

Ash   1.90 

Cane-sugar     40.50 

Water     26.49 


ANIMAL  FOODS  115 

Peerless  Evaporated  Cream. 

Milk-sugar  and   piou m    20.93 

Fat    !».52 

Ash    1 .90 

Water   67.65 

Evaporated  cream  is  merely  a  trad©  name  to  distinguish  un- 
sweetened condensed  milk  from  sweetened  condensed  milk.  A  con- 
densed cream  would,  of  course,  be  butter. 

Condensed  milk  is  largely  used  as  a  substitute  for  fresh  milk  by 
many  people,  and  is  of  especial  value  in  the  tropics  and  on  voyages, 
as  well  as  being  a  useful  food,  under  certain  conditions,  for  infants. 
It  is  easily  digested,  and  the  better  brands  are  reasonably  pure;  but, 
in  the  dilutions  usually  used,  it  is  too  high  in  sugar  percentage  and 
too  low  in  fat.  It  produces  fat,  pale,  flabby  babies,  with  a  tendency 
to  rickets,  scurvy,  and  a  lowered  resistance  to  infections.  On  the 
other  hand,  it  is  most  valuable  in  infants  with  feeble  digestive  powers 
and  those  who  are  not  gaining  in  weight ;  in  hot  summer  weather 
it  is  to  be  recommended  where  the  fresh  milk  is  of  questionable  purity. 
(See  Infant  Feeding.)  It  should  be  remembered  that  condensed  milk 
may  be  made  from  dirty  milk,  and  so  be  objectionable,  and  that  it 
may  contain  large  numbers  of  bacteria. 

Another  method  of  conserving  milk,  known  as  the  Campbell  method, 
has  been  recently  introduced,  and  the  product  is  now  obtainable  in 
some  places.  Pure  milk  is  placed  in  a  concentrating  vat  and  warmed 
to  140°  F.  A  blast  of  filtered  air  is  driven  through  it  for  about  three 
hours,  or  until  the  original  volume  is  reduced  to  one-quarter.  This  is 
then  bottled  in  sterile  bottles.  It  may  be  used  just  as  it  is  in  coffee 
or  tea,  diluted  one-half  in  place  of  cream,  or  with  three  times  the 
amount  of  water  in  place  of  ordinary  milk. 

Predigestlon  of  Milk. — Milk  may  be  partly  or  wholly  predigested 
in  order  to  render  it  more  easily  digestible  for  individuals  suffering 
from  gastro-intestinal  disorders.  This  process  is  readily  accomplished 
by  adding  an  active  preparation  of  pepsin  to  acidulated  milk,  and 
allowing  the  fermentation  to  proceed  under  the  influence  of  heat  at 
the  body-temperature  by  immersion  in  hot  water.  During  this  fer- 
mentation the  casein  is  partly  or  completely  converted  into  albumoses. 
If  the  process  is  allowed  to  continue  too  long,  the  milk  becomes  bitter. 
For  this  reason  it  is  ordinarily  removed  from  the  hot  water  after  a 
few  minutes,  and  is  placed  upon  ice,  which  prevents  further  fermen- 
tation. In  order  to  predigest  milk  in  alkaline  solution  pancreatin  is 
substituted  for  pepsin ;  pancreatization  of  milk  has  now  largely  re- 
placed peptonization.  In  order  to  effect  pancreatization  of  milk, 
Fairchild's  peptonizing  tubes  are  ordinarily  employed.  These  tubes 
contain  five  grains  of  pancreatic  extract  and  fifteen  grains  of  sodium 
bicarbonate.  Each  tube  contains  sufficient  powder  to  digest  one  pint 
of  milk.  Another  easy  method  of  partially  pancreatizing  milk  is  by 
the  use  of  Fairchild's  peptogenic  milk  powder.     First  dissolve  the 


116  CLASSES  OF  FOOD 

powder  in  the  water  by  rubbing  and  stirring  with  a  spoon,  then  add 
the  milk  and  cream ;  mix  well ;  heat  in  a  saucepan,  with  constant 
stirring  until  blood-warm — not  too  hot  to  be  agreeably  borne  by  the 
mouth;  keep  at  about  this  temperature  for  ten  minutes;  then  bring 
quickly  to  boiling-point ;  pour  at  once  into  clean  bottle,  shake  thor- 
oughly, cork  tightly,  and  place  directly  on  ice  or  in  a  very  cold  place. 

Where  the  taste  of  pancreatized  milk  proves  objectionable,  the  addi- 
tion of  carbonated  waters,  or  of  small  quantities  of  coffee,  may  render 
it  more  palatable. 

The  digestibility  of  milk  may  be  increased  by  the  addition  of  hot  or 
cold  water,  carbonated  waters,  such  as  Vichy  or  Apollinaris,  lime- 
water,  oatmeal  or  barley-water,  or  farinaceous  foods,  such  as  arrow- 
root or  flour;  occasionally  small  quantities  of  salt  or  sodium  bicar- 
bonate are  helpful. 

Kumiss,  Kefir,  and  Matzoon. — Kumiss  is  a  fermented  drink  pre- 
pared by  both  lactic  acid  and  alcoholic  fermentation.  For  many 
centuries  it  has  been  made  from  mares'  milk  by  the  natives  living  near 
the  shores  of  the  Caspian  Sea.  The  milk  is  obtained  from  a  special 
breed  of  mares,  the  animals  being  fed  very  carefully.  The  milk  is 
mixed  with  a  kumiss  ferment,  the  lactic  acid  ferment  converting  some 
of  the  sugar  into  lactic  acid,  while  another  part  of  the  sugar 
is  converted  into  alcohol  and  carbonic  acid ;  a  small  quantity  of 
casein  is  digested.  The  milk  is  constantly  agitated,  and  the  fermen- 
tation allowed  to  proceed  for  a  period  of  twenty-four  hours  or  more. 

Kumiss  is  an  acid,  effervescing  drink,  and  contains  a  very  small 
proportion  of  alcohol.  It  is  very  easily  digested,  being  much  more 
digestible  than  milk.  The  casein  is  so  finely  divided  that  lumps 
cannot  be  formed  in  the  stomach,  and  it  is  easily  acted  upon  by  the 
gastric  secretion.  In  the  United  States  it  has  been  prepared  from 
cows'  milk,  to  which  the  ferment  has  been  added. 

Kumiss  Cure. — In  certain  parts  of  Russia  this  form  of  cure  is  not 
uncommon.  It  consists  in  drinking  small  quantities  of  kumiss  and 
gradually  increasing  them  until  large  quantities  are  taken.  Kumiss 
cures  have  been  prescribed  in  chronic  gastro-intestinal  catarrhs  and 
chronic  catarrhs  of  the  respiratory  tract. 

Kefir  resembles  kumiss,  and  is  often  used  as  a  substitute  for  it.  It 
was  originally  made  in  the  Caucasus  from  cows'  milk  fermented  with 
Saccharomyces  mycoderma,  lactic  acid  fermentation  going  on  at  the 
same  time.  Alcohol,  lactic  acid,  and  albumins  are  formed  as  a  result 
of  the  fermentative  processes.  The  casein  is  partly  digested.  Tablets 
of  the  kefir  ferment  have  been  prepared  by  Jurock,  and  are  sold  under 
the  name  of  kefilac  tablets.  They  render  the  home  manufacture  of 
kefir  an  easy  matter.     (See  Recipes.) 

Yoghurt  Milk. — Yoghurt  has  been  used  in  the  East  for  a  long  time, 
but  has  only  recently  been  introduced  in  this  country.  It  is  a  sour 
Bulgarian  milk,  and  is  highly  nutritious,  and  can  be  used  as  a  substi- 


ANIMAL  FOODS 


117 


tute  for  kumiss  or  kefir.  The  fermentation  in  this  form  of  milk  is  gen- 
erated b,\-  a  ferment  of  a  mixture  of  forms  of  bacteria  containing 
mainly  the  Bacillus  hulgaricus. 

The  composition  of  yoghurt  is:  Protein,  7.4;  sugar,  9.4;  fats,  7.20; 
salts,  1.38 ;  alcohol,  0.20 ;  lactic  acid,  0.8.  Yoghurt  is  very  digestible, 
inasmuch  as  the  casein  and  albumin  contained  therein  are  rendered 
soluble  as  peptones  and  albumoses,  and  the  lime  salts  are  in  solution 
to  68  per  cent. 

This  preparation  of  milk  has  become  especially  prominent  due  to 
the  fact  that  ^letchnikoff  describes  a  life-prolonging  etfect  to  it, 
basing  this  belief  on  the  fact  that  in  Bulgaria,  M'here  yoghurt  is  much 
used,  a  large  number  of  consumers  of  this  preparation  are  said  to 
live  above  100  years  of  age.  While  the  conclusions  of  Metchnikoff 
are  probably  not  entirely  correct,  it  is  a  well-known  fact  that  indi- 
viduals often  thrive  on  this  food,  and  the  decomposition  in  the  intes- 
tine is  favorably  influenced  by  it.  Preparations  much  like  yoghurt 
may  be  prepared  from  the  Bulgarian  bacillus  tablets  made  by  the 
various  manufacturing  chemists. 

Matzoon. — In  this  form  of  milk  lactic  acid  is  produced  by  fermen- 
tation with  a  ferment  obtained  from  Syria.  It  it  thicker  than  kumiss 
and  does  not  contain  alcohol. 

Kumiss,  kefir,  and  matzoon  are  agreeable  forms  of  milk  foods,  are 
easily  digestible,  and  are  especially  useful  in  those  cases  in  which 
milk  cannot  be  taken  or  is  not  well  borne.  The  following  table  is 
taken  from  Hutchinson  and  gives  the  composition  of  kumiss,  kefir, 
etc.: 


Proteid. 

Sugar. 

Fat. 

Salts. 

Alcohol. 

Lactic 
acid. 

Kumiss 

Kefir 

Mares'  milk 

C!ows'   milk 

Buttermilk 

Per  cent. 
2.2 
3.1 
2.6 
3.3 
3.8 

Per  cent. 
1.5 
1.6 
5.5 
4.8 
3.3 

Per  cent. 
2.1 
2.0 
2.5 
3.6 
1.2 

Percent. 
0.9 
0.8 
0.5 
0.7 
0.6 

Per  cent. 
1.7 
2.1 

Percent. 
0.9 
0.8 

0.3 

EGGS 

The  eggs  of  the  hen  are  consumed  in  largest  numbers,  but  those  of 
the  duck,  turkey,  guinea-hen,  and  of  some  wild  fowl  are  also  eaten. 
The  eggs  of  domestic  fowls  vary  in  size  and  appearance,  but  their 
composition  is  about  the  same. 

The  shell  of  a  hen's  egg  constitutes  11  parts,  the  white  57  parts, 
and  the  yolk  32  parts  of  the  entire  weight  of  the  egg.  The  following 
table,  taken  from  Langworthy,^  shows  the  composition  of  hens'  eggs, 
cooked  and  raw;  of  white-shelled  and  of  brown-shelled  eggs;  and  of 
the  yolk  and  white  of  the  egg  of  the  duck,  goose,  turkey,  and  guinea- 
fowl  : 

1  Farmers'  Bulletin  Xo.  128,  United  States  Department  of  Agriculture. 


118 


CLASSES  OF  FOOD 


Average  Composition  of  Eggs. 


Hen: 

Whole  egg  as  purchased  . 

Whole  egg,  edible  portion 

White 

Yolk 

Whole  egg  boiled,  edible 
portion 

White-shelled  eggs  as  pur- 
chased   

Brown-shelled  eggs  as  pur- 
chased   

Duck: 

Whole  egg  as  purchased  . 

Whole  egg,  edible  portion 

White 

Yolk 

Goose : 

Whole  egg  as  purchased  . 

Whole  egg,  edible  portion 

White 

Yolk 

Turkey : 

Whole  egg  as  purchased  . 

Whole  egg,  edible  portion 

White 

Yolk 

Guinea-fowl : 

Whole  egg  as  purchased  . 

Whole  egg,  edible  portion 

White 

Yolk 


Per  ct. 
11.2 


10.7 
10.9 
13.7 


Per  ct. 

cr..-T 

73.7 
86.2 
49.5 

73.3 

65.6 

64.8 

60  8 
70.5 
87.0 
45.8 

59.7 
69.5 
86.3 
44.1 

63.5 
73.7 
86.7 
48.3 

60.5 
72.8 
86.6 
49.7 


Perct. 
11.9 
13.4 
12.3 
15.7 

13.2 

11.8 

11.9 

12.1 
13.3 
11.1 
16.8 

12.9 
13.8 
11.6 
17.3 

12.2 
13.4 
11.5 
17.4 

11.9 
13.5 
11.6 
16.7 


^ 


Per  ct. 

9.30 
10.50 

0.20 
33.30 

12.00 

10.80 

11.20 

12.50 

14.50 

0.03 

36.20 

12.30 
14.40 
0.02 
36.20 

9  70 
1120 

0.03 
32.90 

9.90 
12.00 

0.03 
31.80 


Per  ct. 


Perct. 
0.9 
1.0 
0.6 
1.1 

0.8 

0.6 

0.7 

0.8 
1.0 
0.8 
1.2 

0.9 
1.0 
0.8 
1.3 

0.8 
0.9 
0.8 
1.2 

0.8 
0.9 
0.8 
1.2 


3  3  2 


Calories. 
635 
720 
250 
1705 

765 

675 

695 

750 
860 
210 
1840 

760 
865 
215 
1850 

635 
720 
215 
1710 

640 

755 

215 

1655 


As  may  be  seen  from  the  foregoiiig  table,  the  egg"  contains  mainly 
protein  and  fats,  in  addition  to  water  and  mineral  matter.  The 
white  and  the  yolk  differ  in  composition,  the  white  containing  less  pro- 
tein and  water  than  the  yolk,  and  scarcely  any  fat  and  ash,  whereas  the 
yolk  contains  considerable  fat  and  ash.  The  white  is  said  to  be  pure 
protein ;  it  is  composed  mainly  of  four  albumins  and  a  slight  amount 
of  carbohydrate.  The  albumins  are  ovalbumin,  conalbumin,  ovo- 
mucin, and  ovomucoid,  the  ovalbumin  being  the  main  constituent. 
The  yolk  of  the  egg  is  very  complex  in  composition,  and  contains  15 
per  cent,  of  protein  (vitellin),  20  per  cent,  of  palmitin,  olein,  and 
stearin  (the  fatty  elements),  and  0.5  per  cent,  of  coloring-matter, 
besides  lecithin,  nuclein,  salts  of  iron,  calcium,  potassium,  and  mag- 
nesium ;  the  total  phosphorous  equivalent  in  the  yolk  is  slightly  over  1 
per  cent.,  while  that  of  the  white  is  but  0.03  per  cent.  The  shell  of  the 
hen's  egg  has  no  food-value;  it  consists  mainly  of  mineral  matter  con- 
taining 94  per  cent,  of  calcium  carbonate. 

The  flavor  of  the  e^^  is  dependent  in  large  measure  upon  the  food 
eaten  by  the  laying  hen.  Fresh  eggs  have  the  finest  flavor.  Langwor- 
thy  ^  gives  the  following  methods  for  testing  the  freshness  of  eggs: 
"  'Candling,'  as  it  is  called,  is  one  of  the  methods  most  commonly 
followed.     The  eggs  are  held  up  in  a  suitable  device  against  a  light. 


1  Farmers'  Bulletin  No.  128. 


ANIMAL  FOODS  119 

The  fresh  egg  appears  unclouded  and  almost  translucent ;  if  incuba- 
tion has  begun,  a  dark  spot  is  visible,  which  increases  in  size  according 
to  the  length  of  time  incubation  has  continued.  A  rotten  egg  appears 
dark  colored.  The  age  of  eggs  may  be  approximately  judged  by  tak- 
ing advantage  of  the  fact  that  as  they  grow  old  their  density  decreases 
through  evaporation  of  moisture."  According  to  Siebel,  a  new-laid 
egg  placed  in  a  vessel  of  brine  made  in  the  proportion  of  two  ounces 
of  salt  to  one  pint  of  water  will  at  once  sink  to  the  bottom.  An  egg 
one  day  old  will  sink  below  the  surface,  but  not  to  the  bottom,  while 
one  three  days  old  will  swim  about  just  immersed  in  the  liquid.  If 
more  than  three  days  old,  the  egg  will  float  on  the  surface,  the  amount 
of  shell  exposed  increasing  with  age.  If  the  egg  is  two  weeks  old,  only 
a  little  of  the  shell  will  dip  in  the  liquid.  Penzoldt  ^  gives  the  follow- 
ing table  showing  the  digestibility  of  eggs : 

2  soft-boiled  eggs  leave  the  stomach  in  1%  hours. 

2  raw  eggs  leave  the  stomach  in  2I/4  hours. 

2  poached  eggs  and  5  grams  of  butter  leave  the  stomach  in  2i/^  hours. 

2  hard-boiled  eggs  leave  the  stomach  in  3  hours. 

2-egg  omelet  leaves  the  stomach  in   3  hours. 

Raw  white  of  egg  contains  something  which  enables  it  to  resist 
digestion,  but  this  antitryptic  substance  is  destroyed  by  heating  to  70° 
C.  Raw  white  of  egg  may  leave  the  stomach  rather  quickly  and 
owing  to  its  slow  digestion  is  not  as  well  absorbed  as  if  heated.  Cod- 
dled eggs  and  custards  are  excellent  ways  of  serving  eggs  to  invalids. 
The  use  of  raw  eggs  is  not  advised  by  some  on  account  of  their  tending 
in  some  persons  to  produce  unpleasant  eructations,  nausea  and  head- 
ache. The  white  of  egg  may  be  decomposed  in  the  intestine.  Exces- 
sive quantities  may  cause  albuminuria  and  sensitized  persons  are 
naturally  unpleasantly  affected.  The  raw  white  of  egg  is  utilized  up 
to  about  85  per  cent.  The  chief  value  of  raw  eggs  is  in  the  yolh  and 
so  far  we  have  not  noted  any  deleterious  effect  from  using  raw  eggs 
except  as  noted  above  (see,  however,  Bateman,  American  Journal  of 
the  ^Medical  Sciences,  June,  1917,  p.  841),  but  in  view  of  recent  inves- 
tigation the  value  and  use  of  raw  egg  white  alone  may  be  questioned. 

Raw  eggs  are  best  taken  directly  from  the  shell,  or  they  may  be 
combined  with  milk  broths  or  with  coft'ee.  In  various  diseases  accom- 
panied by  loss  of  flesh  and  strength  raw  eggs  in  large  numbers  are 
prescribed,  as  many  as  24  eggs  being  given  in  twenty-four  hours.' 

The  palatability  of  the  egg  may  be  increased  by  flavoring  it  with 
sherry  wine,  orange,  lemon,  or  grape  juice,  or  by  serving  it  in  cream, 
cocoa,  or  coffee. 

Egg-nog  is  prepared  from  milk  and  eggs,  flavored  with  some  alco- 
holic drink,  and  sweetened  with  sugar. 

When  allowed  to  remain  in  the  air,  eggs  decompose  from  the  en- 

1  Hutchison,  Food  and  Dietetics,  p.  152. 

2  Ely,  "Fable  of  Egg,"  New  York  Med.  Jour.,  November  14,  1903. 


120  CLASSES  OF  FOOD 

trance  of  germs  through  their  shell.  Decomposition  may  be  prevented 
in  various  ways,  such  as  by  coating  them  with  oil  or  varnish,  packing 
them  in  sawdust,  or  placing  them  in  cold  storage  or  in  certain  solu- 
tions, such  as  salicylic  acid  and  glycerin. 

MEATS  AND  THE  MEAT  PREPARATIONS 

Meat  forms  the  fleshy  or  muscular  parts  of  the  body.  It  is  one  of 
the  most  important  articles  of  food,  and  is  the  chief  source  of  man's 
protein  supply.  Meat  may  be  eaten  raw  or  cooked.  Raw  meat,  when 
well  ground,  is  very  easily  digested. 

Meat  is  composed  of  muscle-fibers  held  together  by  connective-tissue 
bands;  between  the  muscle-fibers  are  bits  of  fat.  As  ordinarily  seen, 
meat  contains  muscle  tissue,  connective  tissues,  blood-vessels,  nerVes, 
and  lymphatics,  together  with  a  varying  amount  of  fat.  The  more 
fat  there  is  in  meat,  the  less  water  and  nitrogenous  matter  does  it  con- 
tain, and  vice  versa.  Cooking  has  the  effect  of  rendering  the  connec- 
tive tissues  soluble,  thereby  causing  a  separation  of  the  muscular 
fibers,  allowing  the  digestive  secretion  to  mingle  more  thoroughly  vsdth 
them.  Cooking  also  enhances  the  flavor  and  appearance  of  the  meat, 
but,  on  the  other  hand,  causes  a  loss  in  fat  and  extractives.  Cooking 
likewise  destroys  the  micro-organisms  that  may  be  present  in  the  meat, 
and  thus  renders  it  more  wholesome. 

Meat  may  be  cooked  in  various  ways — it  may  be  boiled,  stewed, 
roasted,  or  fried.  Meat  is  boiled  by  placing  it  in  cold  water  and 
subjecting  it  to  a  moderate  heat  for  some  time.  In  this  way  the  con- 
nective tissue  becomes  gelatinized,  and  a  portion  of  the  organic  salts, 
albumin,  and  extractives  is  dissolved.  The  longer  the  process  is 
allowed  to  continue,  the  more  tasteless  does  the  meat  become  and  the 
richer  is  the  broth.  This  tasteless  mass  of  meat  has  a  high  nutritive 
value,  and,  combined  with  the  broth,  constitutes  a  nutritious  food. 
The  process  of  stewing  meat  is  accomplished  by  placing  the  meat 
in  boiling  water,  by  means  of  which  the  albumin  on  the  surface  is 
quickly  coagulated,  thus  preventing  the  juice  from  escaping  and  so 
retaining  the  flavoring  matter ;  the  broth  that  is  procured  in  this  way 
is  very  poor  in  quality.  Meat  is  roasted  by  placing  it  in  a  very  hot 
oven,  the  superficial  layers  thus  becoming  immediately  coagulated, 
and  so  preventing  escape  of  the  juice.  To  broil  meat,  small  bits  are 
cooke'd  over  an  open  fire,  the  albumin  of  the  surface  being  thus  not 
only  coagulated,  but  the  inner  fibers  being  cooked  at  the  same  time. 
Frying  is  accomplished  by  placing  the  meat  in  boiling  oil ;  the  surface 
albumin  is  at  once  coagulated,  the  juice  is  prevented  from  escaping, 
and  the  meat  is  rapidly  cooked. 

Digestibility  of  Meats. — The  digestibility  of  meats  is  governed 
by  many  conditions :  The  age  at  which  the  animals  eaten  were  killed, 
the  length  of  time  the  meat  is  kept  before  eating,  the  care  bestowed 
upon  the  animals  during  life,  and  the  methods  of  preparing  the  meats 


AMMAL  FOODH 


121 


for  the  table.  Meats  are  most  easily  digested  wlieu  stewed;  frying 
renders  them  most  indigestible.  The  flavor  of  meat  varies  with  the 
condition  of  the  animal  from  which  it  was  obtained.  The  meat  of 
mature  animals  is  more  pronounced  and  agreeable  in  flavor  than  that 
of  younger  cattle. 

The  following  table,  taken  from  Pen^oldt,  gives  the  relative  digest- 
ibility of  meat  foods; 


Tvx)  to  three  hours: 

250  gm.  calf's  brain  boiled. 

250  gm.  sweetbread  boiled. 
Four  to  five  hours: 

210  gm.  roast  pigeon. 

250  gm.  roast  tillet. 

250  gm.  beefsteak  grilled. 

250  gm.  smoked  tongue. 

250  gm.  hare. 

240  gm.  roast  partridg 

250  gm.  roast  goose. 

280  gm.  roast  duck. 


One  to  two  hours: 
200  gm.  beef-juice. 

Three  to  four  hours: 

230  gm.  stewed  young  chicken. 

230  gm.  broiled  partridge. 

240  gm.  stewed  pigeon. 

195  gm.  roast  pigeon. 

250  gm.  beef   (raw  or  boiled). 

250  gm.  calf's  foot,  boiled. 

160  gm.  ham,  boiled. 

100  gm.  roast  veal. 

100  gm.  beefsteak. 

100  gm.  beefsteak  pulp. 

100  gm.  roast  beef. 

Beef. — The  composition  of  beef  varies  greatly,  especially  in  regard 
to  the  amount  of  fat  and  water  it  contains.  An  ox  from  three  to  live 
years  old  supplies  the  best  beef.  The  meat  of  a  very  lean  animal  will 
contain  about  75  per  cent,  of  water  and  about  2  per  cent,  of  fat.  The 
water  in  fat  meat  is  reduced  to  between  50  and  55  per  cent.,  while 
the  fat  reaches  2.5  per  cent,  or  over.  The  amount  of  nitrogenous 
substances  is  also  considerably  reduced  in  fat  meat.  Beef -fat  is  com- 
posed of  the  glycerids  of  the  fatty  acids,  the  ratio  being  three  parts 
of  stearic  and  palmitic  acids  to  one  part  of  oleic  acid. 

Meat  Preparations. — Numerous  meat  preparations,  both  solid  and 
liquid,  are  now  on  the  market,  the  aim  being  to  produce  a  concen- 
trated food  that  will  be  readilj^  digested.  The  different  beef-juices 
have  but  slight  nutritive  value,  most  of  them  containing  only  4  or  5 
per  cent,  of  protein;  their  chief  value  lies  in  the  fact  that  they 
stimulate  the  appetite. 

Bouillons. — Bouillons  are  prepared  by  cutting  meat  into  small  bits, 
heating  slowly  in  water  for  a  time,  and  then  boiling  it  quickly.  The 
fluid  thus  produced  has  a  very  agreeable  flavor,  but  its  nutrient  value 
is  exceedingly  small,  as  it  contains  only  extractives,  salts,  and  a  very 
minute  quantity  of  gelatin.  Bouillons  increase  the  flow  of  the  diges- 
tive secretions,  and  can  be  rendered  more  nutritious  by  the  addition 
of  an  egg,  certain  cereals,  or  vegetables. 

Beef=extracts. — Beef-extracts  are  concentrated  bouillons  that  are 
to  be  diluted  at  the  time  they  are  taken.  Their  nutritive  value  is 
about  the  same  as  that  of  bouillon. 

Bouillon  Cubes. — These  are  widely  sold  and  many  people  have  an 


122 


CLASiSES  OF  FOOD 


erroneous  idea  of  their  food  value.  They  consist  very  largely  of  salt, 
varying  from  49  to  72  per  cent,  and  from  3  to  30  per  cent,  of  vegetable 
extracts  and  from  8  to  28  per  cent,  of  meat  extract.  They  possess  but 
little  nutritive  value,  but  stimulate  the  appetite.  They  should  be 
avoided  by  persons  with  diseased  kidneys. 

Beef=juice. — To  produce  a  nutritious  liquid  beef  preparation  the 
meat  should  be  boiled  slightly  and  then  cut  into  small  pieces  and 
pressed  through  a  lemon-squeezer  or  a  meat-press.  In  this  way  con- 
siderable quantities  of  protein,  in  addition  to  the  salts  and  extractives, 
are  obtained.  The  beef-juices  sold  on  the  market,  such  as  Valentine 's, 
are  prepared  by  subjecting  the  meat  to  strong  pressure.  These  prep- 
arations contain  from  5  to  10  per  cent,  of  protein. 

Meat  Powders. — The  nutritive  value  of  these  preparations  varies 
greatly.  Those  most  frequently  used  are  a  number  of  peptones, 
Somatose,  and  the  Mosquera  ' '  Beef  Meal. ' ' 

Meat=jeines. — Meat-jellies  are  frequently  given  to  invalids,  and  are 
an  agreeable  means  of  administering  protein  food.  Although  they 
do  not  entirely  replace  the  protein  in  the  tissues  they  produce  a  con- 
siderable quantity  of  energy.  According  to  Bauer,  "By  the  addit,ion 
€f  gelatin  very  large  quantities  of  albumin  can  be  spared  in  the  body 
or  devoted  to  increase  of  bulk,  just  as  by  the  suj^ply  of  fats  and 
carbohydrates."  Meat-jelly  is,  therefore,  a  protein-sparer.  Among 
those  most  commonly  employed  are  calf 's-foot  and  calf  s-head  jelly. 

The  following  table,  taken  from  Chittenden,^  gives  the  percentage 
composition  of  beef-products : 


Percentage  Cdmposition 

of  Beef-products  {Analyzed,  1891). 

0 
g 

0 

■5 

g 

'S 
.2" 

2 

'3 

So. 

Constituents. 

V 
to   V 

2-° 

y  0) 

■a  .2 

0 
*c3 

_c   11  CO 

SI 

2 

< 

S'3 
> 

■53 
>i"'^ 

^ 

V 

0 
M 

^1 

0 

■BSi 
< 

Water  (at  110°  C.) 

20.06 

14.03 

60.31 

57.88 

81.09 

83.89 

39.58 

6.80 

6.68 

Solid  matter  (at  110°  C.) .   -   • 

79  94 

S5.97  1  39.69 

42.12 

18.91 

16.01 

60.42 

93.20 

93.32 

Soluble  in  water 

79.9-i 

85.97 

39.69 

42.12 

18.91 

16.01 

50.40 

48.12 

3126 

Insoluble  in  water 

.    . 

10.02 

45.06 

62.06 

Inorganic  constituents  .  .   . 

24.04 

28.29 

11.30 

17.52 

1.02 

6.66 

13.52 

5.08 

4.23 

Phosphoric  acid  1P2O5),    .   .   . 

9.13 

7.28 

4.00 

3.94 

0.03 

0.09 

3.91        1.40 

1.71 

Fat,  ether  extractives  .... 

0.91 

1.27 

0.78 

0.85 

1.49 

0.27 

1.29 

2.95 

13.60 

Soluble  in  80  per  ct.  alcohol 

55.72 

67.92 

29.15 

35.08 

1.49 

0.27 

34.10 

2.95 

13.60 

Total  nitrogen 

9.52 

8.80 

2.68 

3.25 

2.43 

2.29 

7.38 

4.42 

12.36 

Nitrogen  of  insoluble  matter 

9.52 

8.80 

2.68 

3.25 

2.43 

2.29 

1.46 

3.25 

7.65 

Insoluble  proteid  matter    .  . 

9.52 

8.80 

2.68 

3.25 

2.43 

2.29 

9.12 

20.30 

47.81 

Soluble  albumin  (coagulative 

by  heat) 

0.06 

0.68      0.55 

0.47 

13.98 

14.29 

Soluble  albumoses 

5.44 

11.09 

Peptone 

1.87 

18.34 

Total  proteid  matter  avail- 

able as  nutriment 

0.06 

0.68      0.55 

0.47 

13.98 

14.29 

9.12 

27.61 

77.24 

Nutritive  value  as  compared 

with  fresh  lean  beef  (lean 

beef,  100) 

0.30 

3.15 

2.80 

2.40 

72.40 

74.00 

47.20 

143.00 

400.00 

1  Proceedings  of  Philadelphia  County  Medical  Society,  1891,  p.  150. 


ANIMAL  FOODS 


123 


An  examination  into  the  chemie  composition  of  beef  preparations 
has  recently  been  made  by  Dr.  E.  L.  Whitney,  Professor  of  Physiologic 


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124  CLASi^ES  OF  FOOD 

Chemistry  in  the  Baltimore  Medical  College,  and  his  assistant,  Dr.  C. 
A.  Clapp.  A  report  of  these  valuable  analyses  in  advance  of  their 
publication  has  been  furnished  the  authors  by  Professor  Whitney. 

Veal. — Veal  is  tough  and  indigestible,  especially  when  obtained 
from  animals  that  are  killed  too  young.  It  difit'ers  considerably  in 
flavor  from  beef,  and  contains  more  gelatin  than  the  latter.  As  in 
many  persons  veal  has  a  tendency  to  produce  indigestion,  it  is  to  be 
avoided  in  all  cases  of  digestive  debility. 

Mutton. — Mutton  is  considered  more  digestible  than  beef  by 
English  writers,  probably  because  in  England  the  average  mutton  is 
more  tender  than  that  obtained  in  the  United  States ;  the  beef,  how- 
ever, is  inferior  to  that  raised  in  this  country.  Its  fiber  is  finer,  but 
it  contains  more  fat  than  does  beef.  Mutton  fat  contains  a  larger  pro- 
portion of  glycerids  of  stearic  acid,  which  makes  it  more  solid  and  less 
digestible  than  the  fat  of  beef. 

Lamb. — Lamb,  when  of  the  right  age  and  tenderness,  is  as  digestible 
as  beef  or  mutton,  but  it  contains  entirely  too  much  fat. 

Venison. — Unless  obtained  from  young  animals,  when  it  is  tender, 
highly  flavored,  and  short-fibered,  venison  is  apt  to  be  difficult  of 
digestion.  On  account  of  its  stimulating  action  it  should  be  avoided 
by  dyspeptics  and  others  with  weak  stomachs. 

Pork. — Pork  is  the  most  indigestible  of  all  meats  on  account  of  the 
large  percentage  of  fat  that  it  contains.  This  fat  consists  chiefly  of 
the  glycerids  of  palmitic  and  oleic  acids,  and  may  be  present  in  the 
proportion  of  37  per  cent,  or  more. 

Ham  and  Bacon. — Ham  and  bacon  are  both  more  digestible  than 
pork.  In  some  parts  of  Germany  ham  plays  quite  an  important  part 
in  invalid  dietaries,  but  in  England  and  America  it  is  seldom  pre- 
scribed. Bacon  is  used  largely  as  an  army  ration.  When  cooked 
crisp,  thin  slices  of  bacon  are  easily  digested. 

Horse  Meat. — Horse  meat  is  not  used  for  food  in  the  United  States 
or  in  England,  but  is  consumed  in  large  quantities  in  France  and  Ger- 
many, and  to  a  less  extent  in  some  other  European  countries. 

Rabbit. — When  young,  rabbit  meat  is  quite  digestible,  but  it  is 
usually  omitted  from  diet-lists. 

Fowl. — Chicken  is  one  of  the  most  digestible  and  agreeable  varieties 
of  meats.  The  meat  of  young  pigeons  also  is  especially  digestible ;  that 
of  ducks  and  geese  contains  too  much  fat. 

The  flesh  of  game  is  easily  digested,  the  meat  of  the  breast  being 
best  adapted  for  invalid  use. 

The  table  on  page  125,  taken  from  Atwater,^  gives  the  general  com- 
position of  the  various  meats : 

1  Principles  of  Nutrition,  United  States  Department  of  Agriculture,  p.  16. 


ANIMAL  FOODS 


125 


Food-materials  (as  pur- 
chased). 


Beef,  fresh : 

Chuck  ribs 

Flank 

Loin 

Porterhouse  steak    .... 

Sirloin  steak 

Neck 

Ribs 

Rib  rolls 

Round    

Rump 

Shank,  fore 

Shoulder  and  clod    .... 

Forequarter 

Hindquarter  .  .  .  .  . 
Beef,  corned,  canned,  pick- 
led, and  dried: 

Corned  beef 

Tongue,  pickled 

Dried,  salted,  and  smoked 

Canned  boiled  beef .... 

Canned  corned  beef  .  . 
Veal: 

Breast 

Leg 

Leg  cutlets 

Forequarter 

Hindquarter 

Mutton : 

Flank 

Leg,  hind 

Loin  chops 

Forequarter 

Hindquarter,  without  tal- 
low     

Lamb: 

Brea.st 

Leg,  hind 

Pork,  fresh: 

Ham  

Loin  chops 

Shoulder       

Tenderloin 

Pork,  salted,  cured,  and 
pickled : 

Ham,  smoked ■ 

Shoulder,  smoked    .  .   .  . 

Salt  pork 

Bacon,  smoked  ...... 

Sausage • 

Bologna 

Pork 

Frankfort 

Soups : 

Celery,  cream  of 

Beef 

Meat  stew 

Tomato 

Poultry : 

Chicken,  broilers 

Fowls 

Goose 

Turkev   


Refuse.  Water 


Percl.      Perct. 


Pro- 
tein. 


16.3 
10.2 
13.3 
12.7 
12.8 
27.6 
20.8 


7.2 
20.7 
36.9 
16.4 
18.7 
15.7 


8.4 
6.0 
4.7 


21.3 
14.2 
3.4 
24.5 
20.7 

9.9 
18.4 
16.0 
21.2 

17.2 

19.1 
17.4 

10.7 
19.7 
12.4 


13.6 
18.2 


7.7 
3.3 


41.6 
25.9 
17.6 
22.7 


52.6 
54.0 
52.5 
52.4 
54.0 
45.9 
43.8 
63.9 
60.7 
45.0 
42.9 
56.8 
49.1 
50.4 


49.2 
58.9 
53.7 
51.8 
51.8 

52.0 
60.1 
68.3 
54.2 
56.2 

39.0 
51.2 
42.0 
4L6 

45.4 

45.5 
52.9 

48.0 
41.8 
44.9 
66.5 


34.8 
36.8 
7.9 
17.4 

55.2 
39.8 
57.2 

88.6 
92.9 
84.5 
90.0 

43.7 
47.1 
38.5 
42.4 


Perct. 

15.5 
17.0 
16.1 
19.1 
16.5 
14.5 
13.9 
19.3 
19.0 
13.8 
12.8 
16.4 
14.5 
15.4 


14.3 
11.9 
26.4 
25.5 
26.3 

15.4 
15.5 
20.1 
15.1 
16.2 

13.8 
15.1 
13.5 
12.3 

13.8 

15.4 
15.9 

13.5 
13.4 
12.0 
18.9 


14.2 
13.0 
1.9 
9.1 

18.2 
13.0 
19.6 

2.1 
4.4 
4.6 
1.8 

12.8 
13.7 
13.4 
16.1 


Fat. 


Per  ct. 

15.0 
19.0 
17.5 
17.9 
16.1 
11.9 
21.2 
16.7 
12.8 
20.2 
7.3 
9.8 
17.5 
18.3 


23.8 
19.2 
6.9 
22.5 
18.7 

11.0 
7.9 
7.5 
6.0 
66 

36.9 
14.7 
28.3 
24.5 

23.2 

19.1 
13.6 

25.9 
24.2 
29.8 
13.0 


33.4 
26.6 
86.2 
62.2 

19.7 
44.2 
18.6 

2.8 
0.4 
4.3 
1.1 

1.4 
12.3 
29.8 
18.4 


Carbo- 
hy- 
drates. 


Perct. 


1.1 
1.1 

5.0 
1.1 
5.5 
5.6 


Ash. 


Perct. 

0.8 
0.7 
0.9 
0.8 
0.9 
0.7 
0.7 
0.9 
1.0 
0.7 
0.6 
0.9 
0.7 
0.7 


4.6 
4.3 
8.9 
1.3 
4.0 

0.8 
0.9 
1.0 
0.7 
0.8 

0.6 

0.8 
0.7 
0.7 


0.8 
0.9 

0.8 
0.8 
0.7 
1.0 


4.2 
5.5 
3.9 
4.1 

3.8 
2.2 
3.4 

1.5 
1.2 
1.1 
1.5 

0.7 
0.7 
0.7 
0.8 


Fuel- 
value 
per 
pound. 


Oalor. 

iet. 

910 
1106 
1025 
1100 

975 
1166 
1135 
1056 

890 
1090 

545 

715 

995 
1046 


1245 
1010 
790 
1410 
1270 

745 
626 
695 
535 
580 

1770 
890 
1415 
1235 

1210 

1075 
860 

1320 
1245 
1450 


1635 
1335 
3555 
2715 

1155 
2075 
1165 

235 
120 
365 
185 

305 
765 
1475 
1060 


Animal  Viscera. — Animal  viscera  are  not  so  nutritions,  although 
some  of  them  are  quite  as  digestible  as  most  meats.  Tripe,  liver,  kid- 
ney, and  brains  are  eaten  very  extensively.  The  heart  is  tough,  in- 
digestible, and  but  seldom  eaten.  The  blood  of  the  pig  has  been  made 
into  a  form  of  pudding  and  is  relished  by  some.  Sweetbreads — either 
the  pancreas  or  the  thymus  gland  of  the  calf — are  easily  digested. 
See  also  Purin  Nitrogen. 


126 


CLASSES  OF  FOOD 


The   following  table,   compiled   by  Hutchison,^   gives  the  general 
composition  of  animal  viscera  : 

Composition  of  Animal  Viscera. 


Kidney  (ox) 

Kidney  (sheep) 

Liver  (ox)    .' 

Liver  (sheep)  

Heart  (ox) 

Heart  (sheep) 

Lung  (ox) 

Lung  (sheep) 

Sweetbreads 

Blood     

Tripe 

Tongue  (ox),  fresh  .  .  .  . 
Tongue,  smoked  and  salted 
Brain 


Water. 


76.7 
78.7 
71.2 
61.2 
62.6 
69.5 
79.7 
75.9 
70.9 
80.8 
74.6 
63.8 
35.7 
80.6 


Nitro- 
genous 
mattter. 


16.9 
16.8 
20.7 
23.1 
16.0 
17.0 
16.1 
20.2 
16.8 
18.1 
16.4 
17.1 
24.3 


Fat. 


Carbo- 
hydrates. 


4.8 

3.2 

4.5 

9.0 

20.4 

12.6 

3.2 

2.8 

12.1 

0.2 

18.5 

18.1 

31.6 

9.3 


0.4 

1.5 
5.0 


Ash. 


1.20 
1.30 
1.60 
1.70 
1.00 
0.90 
1.00 
1.20 
1.60 
0.85 
0.50 
1.00 
8.50 
1.10 


FISH 

The  different  kinds  of  tish  vary  widely  in  their  nutritive  and 
digestive  qualities.  For  example,  the  flounder  and  the  oyster  are 
much  easier  of  digestion  than  those  that  contain  a  large  amount  of 
fat,  like  the  salmon  and  the  herring.  Eels  contain  the  greatest  pro- 
portion of  fat,  which  may  reach  28  per  cent.  White-fleshed  fish,  as  a 
rule,  contain  little  fat. 

All  fish  are  best  in  season ;  out  of  season  they  lose  flavor  and  have  a 
diminished  nutritive  value,  and  in  some  cases  develop  an  off'ensive 
odor.  These  changes  are  due  chiefly  to  the  change  in  food.  Fish  are 
in  best  condition  just  before  spawning ;  after  this  process  they  become 
thin  and  unfit  for  foot.  The  flavor  of  some  varieties,  such  as  the  ray 
and  the  turbot,  is  improved  by  keeping. 

On  account  of  the  rapid  changes  they  undergo  by  way  of  decom- 
position, fish  should  always  be  eaten  in  as  fresh  a  condition  as  possible. 
Various  methods  have  been  resorted  to  with  a  view  to  preventing  these 
changes.  There  are  many  modern  contrivances  for  preserving  fish, 
and  drying,  smoking,  pickling,  salting,  and  canning  are  practised  on  a 
large  scale.     These  methods  all  modify  the  flavor  more  or  less. 

There  are  several  varieties  of  fish  that  are  poisonous.  These  are, 
however,  confined  chiefly  to  tropical  waters.  The  parasites  that  may 
be  present  in  fish  are  destroyed  during  the  cooking.  Ptomain-poison- 
ing  is  of  rather  rare  occurrence.  The  table  on  pages  127,  128,  taken 
from  Lang^vorthy,-  gives  the  composition  of  the  fish  most  commonly 
eaten : 

1  Food  and  Principles  of  Dietetics,  p.  79. 

2  "Fish  as  Food,"  Farmers'  Bulletin  No.  85,  United  States  Department  of  Agri- 
culture, 1898,  p.  12. 


ANIMAL  FOODS 


127 


Jomposiiion  of  PUh. 


Riad  of  food-material. 


Fresh  fish. 

Alewife,  whule 

Bass,    large-mouthed    black, 

dressed 

Bass,    large-mouthed    black, 

whole 

Bass,   small-mouthed  black, 

dressed 

Bass,   small-mouthed  black, 

whole 

Bass,  sea,  dressed 

Bass,  sea,  whole 

Bass,  striped,  dressed  .   .   .   . 

Blackfish,  dressed 

Bluefish,  dressed 

Butterfish,  dressed 

Butterfish,  whole 

Carp  (European  analysis)  . 

Cod,  dressed 

Cod,  steaks     

Cusk,  dressed 

Eel,  salt-water,  dressed  .  .  . 
Flounder,  common,  dressed 
Flounder,  winter,  dressed    . 

Hake,  dressed 

Haddock,  dressed 

Halibut,  dressed 

Herring,  whole 

Mackerel,  dressed 

Mackerel,  Spanish,  dressed  . 
Mackerel,  Spanish,  whole  .  . 

Mullet,  dressed 

Mullet,  whole • 

Perch,  white,  dressed  .... 

Perch,  white,  whole 

Perch,  yellow,  dressed    .  .   . 

Pickerel,  dressed 

Pickerel,  whole 

Pike,  dressed 

Pike,  whole 

Pollock,  dressed 


Percl. 

49.5 

46.7 

56.0 

46.4 

53.6 
46.8 
56.1 
51.2 
55.7 
48.6 
34.6 
42.8 
37.1 
29.9 
9.2 
40.3 
20.2 
57.0 
56.2 
52.5 
51.0 
17.7 
46.0 
40.7 
24.4 
34.6 
49.0 
57.9 
54.6 
62.5 
35.1 
35.9 
47.1 
30.5 
42.5 
28.7 


Perct. 


Per  cl. 
37.5 


40.1 

34.7 
42.2 
34.8 
37.4 
35.0 
40.3 
45.8 
40.1 
48.4 
58.5 
72.4 
49.0 
57.2 
35.8 
37.0 
39.5 
40.0 
61.9 
37.3 
43.7 
51.4 
44.5 
38.2 
31.5 
34.4 
28.4 
50.7 
51.1 
42.2 
55.4 
45.7 
54.3 


Perct. 

9.7 

10.3 


11.5 

10.0 

10.1 

8.3 

8.7 

8.3 

9.8 

11.7 

10.2 

12.9 

10.6 

16.9 

10.1 

14.6 

6.3 

6.1 

7.2 

8.2 

15.1 

10.0 

11.4 

15.8 

13.7 

9.8 

8.1 

8.7 

7.2 

12.6 

11.9 

9.8 

13.0 

10.7 

15.5 


Perct. 
2.5 


1.3 

1.1 
0.2 
0.2 
2.2 
0.5 
0.6 
7.2 
6.3 
0.7 
0.2 
0.5 
0.1 
7.2 
0.3 
0.2 
0.3 
0.2 
4.4 
5.9 
3.5 
7.2 
6.2 
2.4 
2.0 
1.8 
1.5 
0.7 
0.2 
0.2 
0.4 
0.3 
0.6 


.5  6 


Perct. 


Perct. 

0.8 
0.6 


0.7 

0.6 
0.7 
0.6 
0.5 
0.5 
0.7 
0.7 
0.6 
0.9 
0.8 
1.0 
0.5 
0.8 
0.6 
0.5 
0.5 
0.6 
0.9 
0.8 
0.7 
1.2 
1.0 
0.6 
0.5 
0.5 
0.4 
0.9 
0.9 
0.7 
0.7 
0.6 
1.1 


Perct. 
13.0 


5s 


Oaior- 
ie*. 
286 

216 

176 

270 


11.7 

2ao 

11.0 

195 

9.1 

160 

11.4 

255 

9.3 

176 

11.1 

205 

19.6 

520 

17.1 

456 

14.5 

270 

11.6 

206 

18.4 

335 

10.7 

190 

22.6 

576 

7.2 

130 

6.8 

120 

8.0 

145 

9.0 

160 

20.4 

465 

16.7 

436 

15.6 

360 

24.2 

595 

20.9 

516 

12.8 

285 

10.6 

235 

11.0 

236 

9.1 

196 

14.2 

265 

13.0 

230 

10.7 

190 

14.1 

260 

11.6 

210 

17.2 

316 

Table  continued  on  page  128 

Crustaceans. — The  most  popular  of  the  crustaceans  are  the  crab 
and  the  lobster.  They  are  highly  nutritious,  but  at  the  same  time 
highly  indigestible.  In  some  persons  the  crab  and  the  lobster  are 
especially  apt  to  bring  on  nausea,  vomiting,  and  other  and  more 
distressing  conditions. 

Shellfish. — Oysters,  clams,  and  mussels  are  the  forms  of  shellfish 
chiefly  eaten.  Oysters,  when  eaten  fresh  and  raw,  constitute  the  most 
digestible  animal  food,  but  when  cooked,  their  digestive  value  is 
much  lowered.  The  soft  part  is  proportionately  larger  and  more 
nutritious  than  the  corresponding  portion  of  the  clam.  The  hard  or 
muscular  portion  is  tough  and  rather  indigestible,  and  is  best  omitted 
from  invalid  dietaries.  Oysters  should  never  be  fried  for  the  sick. 
It  may  be  well  here  to  call  attention  to  the  practice  of  "fattening" 
oysters  for  the  market ;  this  is  done  by  placing  them  in  either  fresh  or 
salt  water  for  a  definite  length  of  time,  which  gives  them  a  fresh  and 
plump  appearance.     If  the  water  used  for  this  purpose  contains  sew- 


128 


CLASSES  OF  FOOD 


Composition  of  Fish  ( Continued), 


Kind  of  food-material. 


O  o 


d 

'53 

2 

la 

Perc<. 

Per  ct. 

10.2 

4.3 

8.6 

2.4 

7.4 

2.1 

8.4 

0.2 

9.6 

0.6 

16.5 

17.0 

14.6 

9.5 

10.3 

5.4 

9.2 

4.8 

23.4 

3.8 

10.0 

1.0 

15.4 

1.6 

8.2 

0.3 

6.8 

0.2 

11.7 

1.3 

9.8 

1.1 

12.4 

6.6 

7.9 

8.7 

6.8 

7.5 

10.2 

1.3 

8.4 

1.1 

12.5 

3.6 

10.3 

3.0 

10.5 

2.5 

14.7 

15.1 

16.0 

0.4 

22.1 

0.3 

30.0 

19.7 

20.2 

8.8 

16.1 

0.1 

19.1 

14.0 

24.0 

12.1 

19.3 

15.3 

19.9 

8.7 

13.8 

21.3 

21.5 

4.1 

21.8 

2.3 

<u  ca 

.sa 


si3 


Fresh  fish. 
Pompano,  dressed  .  . 
Porgy,  dressed  .  . 
Porgy,  whole  .... 
Red  grouper,  dressed 
Red  snapper,  dressed 
Salmon,  California  (sections) 
Salmon,  Maine,  dressed 
Shad,  dressed  .  . 
Shad,  whole  .  .  . 
Shad,  roe  .  .  . 
Smelt,  whole  .  . 
Sturgeon,  dressed 
Tomcod,  dressed 
Tomcod,  whole  . 
Trout,  brook,  dressed 
Trout,  brook,  whole  . 
Trout,  lake,  dressed  . 
Turbot,  dressed  .  .  . 
Turbot,  whole  .... 
Weakfish,  dressed  .  . 
Weakfish,  whole  .  .  . 
Whitefish,  dressed  .  . 
Whitefish,  whole  .  . 
General  average  of  fresh  fish 
as  sold 

Preserved  fish. 

Mackerel,  "  No.  1,"  salted  .   . 

Cod,  salted  and  dried  .... 

Cod, "  boneless  codfish,"  salt- 
ed and  dried 

Caviare 

Herring,  salted,  smoked,  and 
dried 

Haddock,  "findon  haddie," 
salted,  smoked  and  dried  . 

Halibut,  salted,  smoked,  and 
dried 

Sardines,  canned 

Salmon,  canned 

Mackerel,  canned 

Mackerel,  salt,  canned    .  .   . 

Tunny  ^horse-mackerel), 
canned     

Haddock,  smoked,  canned   . 


Per  ct. 

45.5 
53.7 
60.0 
55.9 
48.9 
5.2 
23.8 
43.9 
50.1 


41.9 
14.4 
51.4 
.59.9 
37.9 
48.1 
35.2 
39.5 
47.7 
41.7 
51.9 
43.6 
53.5 

42.0 


33.3 
24.9 


44.4 

32.2 

6.9 
5.0 
3.9 


Per  ct.  Per  ct. 

39.5 
34.6 
29.<» 
35.0 
40.3 
60.3 
51.2 
39.6 
35.2 
71.2 
46.1 
67.4 
39.6 
32.7 
48.4 
40.4 
45.0 
43.1 
37.3 
46.1 
38.0 
39.4 
32.5 


7.1 
17.2 


21.5 


6.5 

1.4 

12.1 

1.0 
1.9 


5.6 


Per  ct. 


Perct.  Perct. 


44.0 


28.1 
40.3 


54.4 
38.1 


49.2 

46.0 
53.6 
59.3 

68.2 
34.8 

72.7 
68.7 


0.5 
0.7 
0.6 
0.5 
0.6 
1.0 
0.9 
0.8 
0.7 
1.6 
1.0 
1.2 
0.5 
0.4 
0.7 
0.6 
0.8 
0.8 
0.7 
0.7 
0.6 
0.9 
0.7 


1.7 
1.2 


1.7 
4.6 


1.9 
5.3 
1.2 
1.3 
2.1 

1.7 
1.6 


15.0 
11.7 
10.1 
9.1 
10.8 
34.5 
25.0 
16.5 
14.7 
28.8 
12.0 
18.2 
9.0 
7.4 
13.7 
11.5 
19.8 
17.4 
15.0 
12.2 
lO.l 
17.0 
14.0 

14.0 


31.5 

17.6 

24.1 
60.9 

29.9 

17.2 

35.0 
41.4 
35.8 
29.9 
37.2 

27.3 
25.7 


auor. 

its. 
370 
260 
226 
165 
205 

1025 
675 
420 
375 
595 
230 
355 
165 
136 
275 
230 
510 
515 
440 
246 
200 
385 
320 

300 


910 
316 


425 
1630 


305 

945 
956 

1006 
735 

1156 

575 
506 


age,  contamination  is  sure  to  follow.  Oysters  have  in  many  cases  been 
the  carriers  of  typhoid  fever,  and  many  persons  have  been  infected 
in  this  way. 

Clams  are  a  popular  article  of  diet,  and  are  as  agreeable  to  most 
palates  as  oysters.  Mussels  are  consumed  chiefly  by  the  poorer  classes 
in  the  seaport  towns  of  England. 

Langworthy  ^  gives  the  table,  on  the  next  page,  of  the  average  com- 
position of  mollusks,  crustaceans,  etc. : 

1  "Fish  as  Food,"  Farmers'  Bulletin  No.  85,  United  States  Department  of  Agri- 
culture,  1898,  p.  13. 


VEGETABLE  IVODS 


129 


Composition  of  Mollusks,  Crustaceam,  etc. 


Kind  of  food-material. 


Mollusks. 
Oysters,  solid  .... 
Oysters,  in  shell  .   . 
Oysters,  canned    .   . 

Scallops 

Long  clams,  in  shell 
Long  clams,  canned 
Round  clams,  removed  from 

shell 

Round  clams,  in  shell 
Round  clams,  canned 

Mussels 

General  average  of  mollusks 

(exclusive  of  canned)   .   .   . 

Crustaceans. 

Lobster,  in  shell 
Lobster,  canned   . 
Crawfish,  in  shell 
Crab,  in  shell .   . 
Crab,  canned  .   .   , 
Shrimp,  canned 
General  average  of  crustace- 
ans (exclusive  of  canned)  . 

Terrapin,  turtle,  etc. 

Terrapin,  in  shell       

Green  turtle,  in  shell     .... 
Average  of  turtle  and  terrapin 

Frogs'  legs 

General  average  of  fish,  mol- 
lusks, crustaceans,  etc.     .   . 


Per  cl. 
82.3 


43.6 


68.3 
49.3 
60.2 

62.1 

87.7 
55.8 


73.7 


79.0 
76.0 
77.5 
32.0 

44.0 


Per  ct. 


Perct. 

88.3 
15.4 
85.3 
80.3 
48.4 


80.8 
27.3 
83.0 
42.7 

34.0 


31.1 

77.8 
10.0 
34.1 
80.0 
70.8 

20.9 


15.6 
19.1 
17.4 
57.0 

42.5 


Per  ct. 

6.1 
1.1 

7.4 
14.7 
4.8 
9.0 

10.6 
2.1 

10.4 
4.4 

3.2 


5.5 
18.1 
2.0 
7.3 
15.8 
25.4 

4.3 


4.5 
4.5 
4.2 
10.2 

10.0 


• 

CO  *j 

^  *^ 
01  as 

.sa 
IS 

S 

a 

11 

Eh 

Perct. 

Perct. 

Perct. 

Perct. 

1.4 

3.3 

0.9 

11.7 

0.2 

0.6 

0.4 

2.3 

2.1 

3.9 

1.3 

14.7 

0.2 

3.4 

1.4 

19.7 

0.6 

1.1 

1.5 

8.0 

1.3 

2.9 

2.3 

15.5 

1.1 

5.1 

2.3 

19.2 

0.1 

1.3 

0.9 

4.4 

0.8 

3.0 

2.8 

17.0 

0.5 

2.1 

1.0 

8.0 

0.4 

1.3 

0.9 

5.8 

0.7 

0.6 

6.8 

1.1 

0.6 

2.4 

22.2 

0.1 

0.1 

0.1 

2.3 

0.9 

0.5 

1.4 

10.1 

1.5 

0.8 

1.9 

20.0 

1.0 

0.2 

2.6 

29.2 

0.4 

0.2 

0.5 

5.4 

0.7 

0.2 

5.4 

0.1 

0.3 

4.9 

0.7 

0.2 

5.1 

0.1 

0.7 

11.0 

2.5 

0.1 

0.9 

13.5 

la 

Calo- 
ries. 
235 
40 
300 
345 
135 
275 

340 

65 

285 

140 


130 
395 
45 
185 
370 
520 


115 

90 

105 

210 

295 


VEGETABLE  FOODS 

Vegetable  foods  differ  from  animal  foods  especially  in  that  they 
contain  a  large  proportion  of  starch  and  sugar  and  comparatively  a 
small  amount  of  protein.  Yeo  ^  gives  the  following  table  to  show  the 
difference  between  vegetable  and  animal  foods  in  this  regard: 


Fat  beef 
Lean  beef 
Pea-flour 
Wheat   . 
Rice  .    . 


Nitro- 

genous 

Fat. 

Carbo- 

constitu- 

hvdrates. 

ents. 

Per  cent. 

Per  cent. 

Per  cent. 

51.4 

45.6 

. 

89.4 

5.5 

27.3 

0.8 

68.9 

16.6 

0.9 

81.9 

7.7 

0.4 

91.2 

Salts. 


Per  cent. 
3.0 
5.1 
3.0 
0.6 
0.7 


Vegetables  do,  however,  contain  a  certain  amount  of  proteins  and 
fats ;  some  are  rich  in  protein,  others  in  fats. 

Carbohydrates  of  Vegetables. — These  are  starches  and  sugars. 
Starch  is  found  in  all  plants,  and  is  converted  into  dextrin  by  means 

1  Food  in  Health  and  Disease,  p.  66. 


130  CLASSES  OF  FOOD 

of  dry  heat  or  by  cooking.  The  starch-granules  in  vegetables  are  held 
together  by  a  cellulose  framework.  Cellulose  is  a  carbohydrate,  but  is 
very  insoluble ;  it  can  be  utilized  as  a  food  only  when  young;  when  old^ 
it  is  resistant  and  can  not  be  digested,  and  hinders  digestion  of  the 
starches  enveloped  by  it.  Besides  the  starch  and  cellulose,  another 
form  of  carbohydrate,  known  as  pectin,  is  present  in  some  vegetable 
foods.  When  fruit  is  cooked,  this  pectin  gelatinizes,  and  the  jelly 
when  digested  is  converted  into  a  certain  form  of  sugar.  Sugars  are 
also  important  carbohydrates  found  in  vegetables. 

Protein  in  Vegetables. — These  proteins  belong  mainly  to  the 
globulins,  but  in  addition  vegetables  contain  a  large  number  of  nitro- 
genous substances  that  are  not  proteins.  Among  the  various  proteins 
in  vegetables  are  gluten,  as  found  especially  in  flour,  legumen  found 
in  the  legumes,  and  vegetable  protein  found  in  vegetable  juices. 

Extractives  in  Vegetables. — There  is  a  considerable  amount  of 
extractive  matter  in  certain  vegetables,  such  as  asparagus,  which  is 
not  utilized  in  the  bod3^ 

Fats  in  Vegetables. — The  fats  in  vegetables  are  chiefly  in  the  form 
of  oils.  In  addition,  vegetables  contain  a  considerable  amount  of 
water  and  salt.  The  amount  of  water  varies  between  70  and  90  per 
cent.  The  main  mineral  constituents  are  the  salts  of  potassium  and 
sodium  united  with  organic  acids. 

Digestibility  of  Vegetables. — The  digestion  of  vegetables  takes 
place  mainly  in  the  intestine.  Owing  to  the  greater  bulk  of  vegetable 
food  and  to  the  cellulose  that  surrounds  vegetable  cells  and  thus 
prevents  the  ready  access  of  the  digestive  juices,  vegetable  food  is 
not  so  easily  digested  as  animal  food.  (For  an  account  of  the  ab- 
sorbability of  vegetable  foods  the  reader  is  referred  to  the  section  on 
that  subject.)  For  convenience  of  description  the  following  classifi- 
cation of  vegetable  foods  has  been  adopted : 

1.  Cereals.  5.  Fruits. 

2.  Legumes.  6.  Nuts. 

3.  Roots  and  tubers.  7.  Fungi. 

4.  Green  vegetables.  8.  Lichens. 

CEREAIS 
Cereals  are  the  most  important  food-products  derived  from  the 
vegetable  kingdom.  Of  this  class  of  foods  those  in  commonest  use 
are  wheat,  corn,  rye,  oats,  barley,  rice,  and  buckwheat.  The  cereals 
are  eaten  chiefly  after  having  been  ground  into  flour  or  meal.  Flour 
is  most  commonly  made  from  wheat  and  rye,  whereas  corn  and  oats 
are  the  chief  sources  of  meal.  Corn  is  also  eaten  in  large  quantities 
whole,  and  barley  and  rice  are  also  eaten  in  this  way.  The  table  ^  on 
the  next  page  gives  the  chemic  composition  of  the  most  common  cereals : 

1  United  States  Department  of  Agriculture,  Office  of  Experiment  Station, 
Bulletin  No.  11,  pp.  16  and  17,  and  Bulletin  No.  28   (Revised  Edition),  p.  56. 


VEGETABLE  FOODS 


131 


Barley 

Buckwheat    .    .    . 

Com  (maize)     .    . 

Kafir  corn     .    .    . 

Oats 

Rice 

Rye    .' 

Wheat : 

Spring  varieties 
Winter  varieties 


Water. 

Protein. 

Fat. 

Carbohydrates. 

Starch, 

Crude 

etc. 

fiber. 

Per  cent 

Per  ce7it. 

Per  cent. 

Per  cent. 

Percent. 

10.9 

12.4 

1.8 

69.8 

2.7 

12.6 

10.0 

2.2 

64.5 

8.7 

9.3 

9.9 

2.8 

74.9 

1.4 

16.8 

6.6 

3.8 

69.5 

1.1 

11.0 

118 

5.0 

59.7 

9.5 

12.4 

7.4 

0.4 

79.2 

0.2 

11.6 

10.6 

1.7 

72.0 

1.7 

10.4 

12.5 

2.2 

71.2 

1.8 

10.5 

11.8 

2.1 

72.0 

1.8 

Ash. 


Per  cent. 
2.4 
2.0 
1.5 
2.2 
3.0 
0.4 
1.9 

1.9 
1.8 


Wheat  is  the  most  important  source  of  Hour,  owing  to  the  fact  that 
it  can  be  raised  in  any  temperate  climate  and  yields  the  best  flour  at 
the  least  expense.  It  is  rich  in  solids  and  contains  little  water.  The 
wheat-grain  is  covered  by  six  layers,  which  form  the  bran.  Of  these 
six,  the  three  outermost  coats  form  the  skin,  and  the  remaining  three 
layers  the  envelop  of  the  grain.  The  outermost  layer  is  called  the 
testa;  the  innermost,  or  cereal  layer,  takes  its  name  from  the  cerealin 
which  it  contains.  Within  the  cerealin  layer,  and  adjacent  to  the 
embryo,  lies  the  endosperm,  which  contains  the  starch.  The  embryo 
lies  at  the  lower  end  of  the  grain.  The  live  outer  layers  are  com- 
posed chiefly  of  cellulose.  The  cereal  layer  is  the  richest  in  nitro- 
genous substances.  The  endosperm  contains  a  large  amount  of 
starch,  a  nitrogenous  substance  called  gluten,  some  sugar,  and  the 
cellulose  of  its  cell-wall. 

Flour  is  made  by  grinding  the  grain  of  the  various  cereals. 
Although  flour  is  made  chiefly  from  wheat  and  ry^e;  barley,  oats, 
maize,  etc.,  are  also  manufactured  into  flour. 

Bread  is  made  by  adding  to  flour  a  definite  proportion  of  water, 
a  little  salt,  and  the  leavening  agent.  The  mixture  or  dough  is  then 
kneaded,  either  with  the  hands  or,  better,  with  a  spoon.  In  the  large 
modem  bakeries  the  kneading  is  done  entirely  by  machinery.  After 
this  the  dough  is  set  aside  for  a  number  of  hours,  during  which  time 
fermentation  takes  place.  It  is  then  molded  into  loaves  and  baked. 
The  leavening  is  dependent  upon  the  action  of  the  yeast  on  the  starch, 
some  of  which  it  converts  into  sugar,  and  then  into  alcohol  and  carbon 
dioxid  gas.  The  gas  causes  bubbles  to  appear  throughout  the  dough, 
and  renders  it  light  and  spongy.  During  the  baking  process  the  yeast 
germs  are  killed  and  the  alcohol  and  carbonic  acid  gas  are  driven 
off.  Hot  or  fresh  bread,  when  masticated,  forms  a  tenacious,  doughy 
mass,  and  hence  is  not  so  digestible  as  stale  bread,  or  bread  that  has 
been  allowed  to  dry  slightly,  for  the  latter  will  crumble  into  fine 
particles  and  so  is  more  thoroughly  mixed  with  the  gastric  juice. 
Toasting  bread  makes  it  more  digestible.  A  slice  of  bread  remains 
in  the  stomach  about  two  and  one-half  hours. 


132 


CLASSES  OF  FOOD 


Next  to  wheat  bread,  which  thus  far  has  alone  been  mentioned, 
rye  bread  is  the  most  important  of  the  breadstuffs.  While  it  is  not 
so  digestible  for  invalids  as  wheat  bread,  it  is  more  laxative  and 
keeps  fresh  longer  than  wheat  bread.  Wheat  and  rye  flour  are  often 
mixed  in  bread-making. 

Pumpernickel  is  a  whole-rye  bread  made  by  the  Germans.  It  is 
slightly  laxative.  Gluten  bread  is  made  from  gluten  flour,  and  is 
used  chiefly  by  diabetics.  The  best  bread  contains  from  40  to  50 
per  cent,  of  gluten.  Biscuits,  pastries,  and  puddings  are  made  by 
adding  to  the  flour  varying  quantities  of  eggs,  sugar,  milk,  butter, 
fruit,  flavoring  extracts,  etc. 

Buckwheat  flour  is  often  made  into  batter-cakes  in  the  United 
States,  but  in  some  parts  of  Russia  buckwheat  porridge  forms  the 
principal  cereal  food.  Bread  made  from  buckwheat  crumbles  and 
does  not  keep  well. 

Prose  and  Millet. — Nansen  studied  the  possibility  of  millet  as  a 
food  for  human  beings.  In  Russia,  China,  and  India  millet  is  used, 
especially  in  times  of  famine.  The  grain  can  be  milled  and  cooked 
very  much  in  the  same  way  as  other  cereals  and  is  rich  in  protein. 
It  lacks  gluten,  however,  and  a  certain  amount  of  wheat  flour  is 
needed  to  produce  a  suitable  bread.  It  has  the  advantage  that  it 
will  grow  in  an  extremely  dry  climate.  (See  Bulletin  525,  United 
States  Dept.  of  Agriculture.) 

Maize  or  Indian  Corn.— This  forms  an  important  part  of  the  diet 
in  many  parts  of  the  country.  The  different  varieties  have  various 
colors,  but  the  nutritive  value  is  approximately  the  same  and  the 
choice  is  very  largely  a  matter  of  taste  and  changes  with  the  locality. 
The  green  corn  boiled  or  roasted  is,  of  course,  popular  in  season  and 
the  dried  corn  from  which  the  covering  has  been  removed  or  hominy 
is  another  staple  dish. 

The  composition  and  fuel  value  are  given  as  follows  by  Lang- 
worthy  and  Hunt  in  the  Farmers'  Bulletin  565,  United  States  De- 
partment of  Agriculture: 

Average  composition  of  corn  and  corn-meal  products. 


Kind  of  material. 


Water. 


Protein. 


Fat. 


Carbohydrates. 


starch, 

sugar, 

etc. 


Crude 
fiber. 


Mineral 
matters. 


Fuel 

value 

per 

pound. 


Corn,  whole  grain,   average. 

Corn,    white    

Corn,    yellow    

Corn     meal      (whole     grain 

ground,    unbolted    

Corn     meal      (whole     grain 

ground),     bolted     

Corn  meal,   granulated    (new 

process)     

Corn     flour,      i.    e.,      finely 

ground  and  bolted  corn 

meal     


Per 
cent. 

10.8 
11.4 
11.9 

12.0 

12.0 

12.5 

12.6 


Per 
cent. 

10.0 
10.8 
10.7 

8.7 

8.9 

9.2 


Per 

cent. 

4.3 

5.0 

4.8 

4.7 


1.9 


Per 
cent. 
71.7 
68.8 
68.9 

71.1 

72.0 

74.4 


Per 
cent. 
1.7 
2.5 
2.5 

2.2 


1.0 


Per 
cent. 
1.5 
1.5 
1.5 

1..3 

1.0 
1.0 


Cal- 
ories. 
1,795 
1,690 
1,690 

1,850 

1,765 

1,770 

1,645 


VEGETABLE  FOODS  133 

The  kernel  consists  of  the  skin,  the  germ  and  the  enclogerm,  which 
acts  as  a  storehouse  for  the  nourishing  of  the  germ  when  it  starts  to 
grow.  The  composition  of  the  flours  varies  greatly  according  to 
the  nature  of  the  milling  process.  The  old  process  left  in  much  that 
is  removed  by  the  new  process.  Removing  the  skin  takes  away  only 
six  one-hundreths  of  the  whole  weight,  but  more  than  half  the  fiber. 
In  modern  milling  the  germ  is  removed  which  takes  away  only  one- 
tenth  of  the  weight,  but  more  than  six-tenths  of  the  fat  and  one- 
sixth  of  the  protein.  The  modern  milling  removes  the  vitamins. 
(See  same  and  the  Deficiency  Diseases  and  Pellagra.) 

Where  corn  is  much  used  there  is  a  natural  tendency  to  balance 
the  diet  by  using  foods  rich  in  protein,  especially  pork  products. 
Corn  is  deficient  in  gluten  and  it  is  difficult  to  make  bread  that  will 
hold  together.  Sometimes  other  flours  are  added  or  the  outside  is 
quickly  browned  so  as  to  hold  the  small  loaf  together. 

Sorghum  is  occasionally  made  into  bread,  but  in  America  it  is 
grown  usually  for  the  molasses  and  syrup  that  may  be  obtained  from 
it. 

Kaoliang. — This  is  a  grain  sorghum  used  in  Africa  and  parts  of 
Asia  (U.  S.  Department  of  Agriculture,  Bureau  of  Plant  Industry, 
1911,  p.  203).  This  plant  will  grow  in  about  the  same  climates  as 
Indian  corn  and  was  introduced  into  America  in  1866,  but  was  dis- 
carded as  a  source  of  sugar.  The  grain  of  this  plant  can  be  milled 
and  forms  a  suitable  food  and  when  mixed  with  gluten-containing 
flours  makes  bread  suitable  for  human  consumption. 

Rice  constitutes  the  staple  food  of  many  of  the  peoples  of  the 
Orient.  It  is  grown  chiefly  in  Asia,  but  is  also  raised  in  some  parts 
of  Europe.  In  the  United  States  rice  culture  is  confined  chiefly  to 
South  Carolina.  Rice  contains  a  large  proportion  of  starch  in 
very  digestible  form,  but  it  is  comparatively  poor  in  other  constit- 
uents. 

Barley  bread  was  used  for  food  by  the  early  Greeks  and  Romans, 
who  also  used  barley  meal  to  a  large  extent  in  the  training  of  their 
athletes.  Since  the  introduction  of  potatoes  as  food,  and  with  the 
cheapening  of  wheat  flour,  barley  bread  has  gradually  fallen  into 
disuse.     Barley-water  is  used  as  a  beverage  for  invalids  and  infants. 

Oats  contain  liberal  proportions  of  fat.  protein,  and  salts,  a  large 
amount  of  starch,  and  considerable  indigestible  cellulose. 

Oatmeal  is  used  to  the  best  advantage  in  making  porridge;  owing 
to  its  lack  of  gluten  it  makes  only  the  poorest  kind  of  bread.  What 
is  known  as  Scotch  §Toats  is  prepared  by  freeing  the  grain  from  its 
outer-husk.  Oatmeal  porridge  is  said  to  act  as  a  mild  laxative  in 
some  persons,  and  to  excite  dyspeptic  symptoms  in  others. 

Breakfast  Foods, — There  are  a  variety  of  preparations  made  from 
cereals  which  have  been  in  recent  years  placed  on  the  market,  the 
chief  characteristics  of  which  are  that  they  have  undergone,  more  or 


134  CLAS^^'iES  OF  FOOD 

less,  preparation  for  immediate  consumption.  For  the  most  part  they 
are  sold  under  trade  names;  the  composition  and  source  of  the  food 
is  given  in  some  eases  and  omitted  in  others.  Briefly  speaking,  they 
contain  about  the  same  amount  of  nutriment  as  the  cereals  from  which 
they  are  made.  Their  palatability  varies  considerably  and  there  is 
no  objection  to  the  use  of  such  articles  of  diet  if  freshly  prepared 
foods  are  obtained  and  the  individual  that  consumes  them  likes  the 
taste.  The  older  packages,  unless  very  carefully  put  up,  are  liable 
to  be  infected  with  insects  or  moulds,  both  of  which  render  the 
product  unfit  for  food.  The  chief  objection  is  the  cost,  which  is  far 
greater  than  the  same  amount  of  food  prepared  from  the  cereal  itself. 

LEGUMES 

Of  the  legumes,  the  pea  and  the  bean  are  the  most  important  food- 
products.  In  the  middle  and  northern  parts  of  Europe  the  pea  is 
the  most  popular  legume,  while  in  the  Mediterranean  countries  the 
bean  predominates.  In  America  peas  and  beans  are  extensively 
raised.  The  peanut  is  an  American  favorite,  but  the  lentil  is  eaten 
only  to  a  very  small  extent. 

The  legumes  contain  a  liberal  proportion  of  protein  (legumin), 
carbohydrates,  and  a  little  fat,  besides  a  large  amount  of  water. 
Although  legumes  contain  a  proportion  of  protein  in  excess  of  that 
of  meat,  a  large  amount  of  fat,  and  considerable  starch,  they  are 
less  easily  digested  than  animal  foods.  As  pointed  out  by  Abel,^  this 
is  due  to  three  reasons: 

"(1)  As  generally  prepared  and  used,  the  nutrients  of  vegetable 
foods  are  inclosed  in  cells  composed  of  cellulose  or  woody  fiber,  which 
is  more  or  less  hard  and  greatly  interferes  with  their  absorption. 

"  (2)  Vegetable  food  is  prone  to  fermentation  in  the  intestine,  thus 
increasing  the  peristaltic  movements,  and,  if  large  amounts  are  eaten, 
hastening  the  food  onward  before  there  has  been  sufficient  time  for 
the  absorption  of  its  contained  nutrients. 

"(3)  The  cellulose  present  acts  as  a  local  irritant  and  produces 
the  same  effect." 

Legumes  are  apt  to  produce  fermentation,  and  in  this  way  occasion 
flatulence  and  gastro-intestinal  distress.  The  digestibility  of  the 
legumes  depends  largely  upon  the  manner  in  which  they  are  prepared 
and  the  amount  that  is  eaten.  Striimpell  ^  has  shown  that  about  40 
per  cent,  of  the  contained  protein  in  cooked  beans  is  left  unabsorbed, 
the  beans  being  eaten  with  the  skins ;  and  that  with  a  flour  made  from 
lentils  only  8.2  per  cent,  of  the  original  amount  of  protein  is  left  un- 
absorbed ;  so  that  when  eaten  simply  cooked,  a  much  larger  proportion 
remains  unabsorbed  than  when  finely  divided  into  a  powder. 

1  Farmers'  Bulletin  No.  121,  United  States  Department  of  Agriculture,  1900, 
p.   18. 

2  Striimpell,  Deutsch.  Arch.  f.  kiln.  Med.,  vol.  xvii.,  p.  108. 


VEGETABLE  FOODti  135 

Beans  form  one  of  the  oldest  forms  of  vegetable  foods,  having  been 
cultivated  by  the  ancient  Greeks,  Romans,  and  Egyptians.  The 
numerous  varieties  used  for  food  have  all  been  improved  by  cultural 
methods.  The  Windsor  bean,  the  one  which  was  first  cultivated,  is 
still  grown  in  Europe,  but  does  not  thrive  well  in  America.  The 
kidney  bean,  the  most  important  species,  is  easily  cultivated,  growing 
rapidly  and  seeding  early.  The  Lima  bean  is  a  great  favorite,  espe- 
cially in  America.  It  is  a  short  flat  bean,  somewhat  like  the  kidney 
in  shape.  This  variety  is  a  climber,  although  bush  Limas  have  been 
developed  by  cultural  methods. 

The  Soy  Bean. — This  bean  {Glycine  hispida),  sometimes  called 
the  soja  bean,  is  an  annual  leguminous  plant  extensively  used  as  a 
food  in  China  and  Japan.  Until  recently  it  has  been  regarded  as  a 
botanic  curiosity  in  the  Occident.  It  has  recently  been  extensively 
used  in  America  as  a  forage  crop,  and  to  improve  the  soil  if  ploughed 
under.  The  plant  is  an  erect  annual,  bearing  pods  containing  from 
two  to  five  beans.  There  are  a  large  number  of  dilferent  varieties, 
which  vary  in  size,  shape,  color,  and  length  of  time  they  take  to 
mature.  In  the  East  the  bean  is  used  in  numerous  ways.  Some  are 
grown  exclusively  for  the  oil  they  contain,  and  it  is  used  for  culinary, 
illuminating,  and  lubricating  purposes.  The  light-colored  beans  are 
eaten  in  soups,  and  the  pods  are  sometimes  picked  green,  boiled,  and 
served  cold  with  a  sprinkling  of  soy  sauce.  The  green  varieties  are 
often  pickled  in  brine  and  eaten  moist  or  dried  with  meals  as  ap- 
petizers; the  same  varieties  are  often  slightly  sprouted,  scalded,  and 
served  with  meals  in  winter  as  a  green  vegetable.  The  bean  forms 
the  basis  of  the  so-called  soy  sauces,  used  as  condiments  all  over  the 
world.  The  Oriental  races  most  frequently  eat  the  bean  in  more  or 
less  cheesy-like  foods,  which  are  prepared  from  it.  The  most  common 
of  these  are  natto,  tofu,  miso,  yuba,  and  shoyu.  Natto  is  a  sort  of 
bean  cheese  made  by  boiling  the  beans  until  they  become  soft  and 
then  placing  the  resulting  mass  in  a  warm  cellar  where  it  ferments. 
Tofu  is  made  by  soaking  the  beans  in  water,  crushing  between  mill- 
stones, and  boiling  in  about  three  times  their  bulk  of  water.  The 
protein  is  precipitated  and  the  resulting  cheese  eaten.  The  white 
milky  liquid  of  the  above  has  nearly  the  composition  of  cows'  milk, 
and  tastes  something  like  malt.  It  may  be  used  in  infant  feeding  to 
advantage  (see  same). 

Americans  may  eat  the  beans  in  nvimerous  ways,  described  under 
the  head  of  soy  bean  cookery  in  the  recipes  at  the  end  of  this  book. 
The  bean  is  of  particular  value  in  diabetes  (see  same).  It  may  be 
used  to  increase  the  protein  of  the  diet. 

There  are  variations  in  the  composition  of  the  different  varieties 
of  beans.  The  yellow  beans  grown  in  America  have  the  following 
composition : 


136  CLASSES  OF  FQOD 

Water   10.13  per  cent. 

Protein     34.63         " 

Fat    17.98 

Nitrogen-free  extract    30.50         '" 

Fiber 3.69 

Ash   3.07 

Calculated  to  a  water-free  basis: 

Protein  38.50  per  cent. 

Fat 20 

The  Cereo  Company,  Tappan,  N.  Y.,  have  made  a  soy  bean  flour 
which  is  most  useful.     It  has  the  following  composition: 

Protein  N.  X.  6.25  44.64  per  cent. 

Fat    19.43 

Mineral  matter 4.20         " 

Moisture     5.26         " 

Crude  fiber    2.35 

Cane-sugar     9.34         " 

Non-nitrogenous  extract 14.78         " 

Starch     None. 

Reducing  sugars None. 

Polarization  normal  weight  due  to  optically  ac- 
tive substance  other  than  cane-sugar  included 
in  protein  and  non-nitrogenous  extract 7.80'         " 

The  percentage  of  protein  in  this  flour  is  almost  one-third  greater 
than  the  percentage  of  protein  in  the  whole  beans.  This  is  caused 
by  removing  the  coarse  fibrous  hulls  which  contain  little  protein. 

Vegetable  food  of  such  composition  certainly  is  remarkable  when 
compared  with  round  of  beef,  medium,  which  contains: 

Protein   19.0  per  cent. 

Fat    12.8 

Moisture    60.7         " 

Each  ounce  of  this  soy  gruel  flour  yields  about  13  grams  of  protein 
and  120  calories,  and  there  are  several  ways  in  which  it  can  be  used : 
1,  As  a  gruel;  2,  in  broths;  3,  in  making  biscuits.  For  composition 
of  soy  gruels,  see  Infant  Feeding. 

The  bean  has  received  attention  from  time  to  time  in  other  coun- 
tries, and  suggestion  comes  in  the  form  of  a  patent  flour  made  by  a 
German  firm,  patented  in  this  country.  This  is  made  by  treating  the 
beans  with  boiling  water  and  0.5  per  cent,  of  sodium  carbonate  until 
the  carbohydrates  and  other  water-soluble  substances  are  removed. 
The  residue  after  being  dried  and  pulverized  is  a  yellow  powder,  con- 
taining the  nutritive  fatty  and  protein  constituents  of  the  beans. 
The  following  articles  may  also  be  consulted: 


VEGETABLE  FOODS 


137 


Ruhrah :  "'The  Soy  Bean  as  an  Article  of  Diet  for  Infants,"  Journal  of  the 
American  Medical  Association,  May  21,  1910,  p.  1G64. 

Friedenwald  and  Ruhriih:  "The  Use  of  the  Soy  Bean  as  a  Food  in  Diabetes," 
American  Journal  of  Medical  Sciences,  December,  1910. 

Ruhrah:  "Further  Observations  on  the  Soy  Bean,"  Ai'chives  of  Pediatrics, 
October,  1911. 

Ruhrah:   "Soy  Bean  Cookery,"  Medical  Record,  September  23,   1911. 

There  are  several  varieties  of  peas,  the  most  important  being  the 
tield  and  the  garden  pea.  The  former  is  generally  used  for  fodder; 
but  one  variety,  the  Canadian  field  pea,  is  grown  for  table  use. 
There  are  many  varieties  of  the  garden  pea.  The  shelling  peas,  the 
kind  in  most  common  use  in  America,  and  the  sugar  pea  are  the  most 
important  varieties. 

The  lentil,  as  has  been  stated,  is  but  little  used  in  the  United 
States.     The  chief  supply  of  lentils  comes  from   Egypt,  very  few 

Composition  of  Fresh  and  Dried  Legumes  compared  with  that  of  other 
Foods.— [Abel}) 


Material. 

s 

03 

'S 
o 

1 

^1 
is" 

< 

> 

Fresh  legumes : 

String-beaus 

Whole  pods  of  Dolichos  sesquipe- 

Per  cl. 
89.2 

71.9 
81.8 
58.9 
68.5 
74.6 
65.9 
93.7 
79.5 
72.7 
85.3 
68.9 
2.1 

10.4 
12.6 
7.5 
8.4 
9.5 
13.0 
10.8 
14.8 
9.2 
15.0 
78.3 
91.5 
94.3 
7.7 
9.6 
12.3 
11.9 
70.0 
54.3 
87.0 
34.2 
73.7 

Per  ct. 
2.3 

4.5 
3.4 
9.4 
7.1 
7.0 
9.4 
1.1 
4.0 
7.0 
3.6 
6.9 
29.3 

18.1 

22.5 

21.9 

25.7 

24.6 

21.4 

34.0 

12.4 

25.8 

5.9 

2.2 

1.6 

0.9 

116.7 

12.1 

11.7 

10.7 

21.3 

30.0 

3.3 

259 

14.8 

Per  ct. 
0.3 

0.5 
04 
0.6 
0.7 
0.5 
0.6 
0.1 
0.3 
0.2 
0.2 
2.5 
46.5 

1.5 
1.8 
1.3 
1.0 
1.0 
1.4 

16.8 
6.7 

38.6 
1.3 
0.1 
0.3 
0.4 
7.3 
1.8 
1.1 
1.0 
7.9 
6.5 
4.4 

33.7 

10.5 

Per  ct. 
7.4 

13.9 
13.7 
29.1 
22.0 
16.9 
22.7 

3.8 
14.6 
18.5 

9.8 
19.6 
17.1 

65.9 
59.6 
65.1 
59.2 
62.0 
60.8 
33.7 
63.3 
24.4 
75.3 
18.4 
5.6 
3.9 
66.2 
75.2 
74.5 
75.8 

'0.'4 
5.0 
2.4 

Per  ct. 

0.8 

1.2 
0.7 
2.0 
L7 
1.0 
1.4 
1.3 
1.6 
1.6 
1.1 
2.1 
5.0 

4.1 

3.5 
4.2 
5.7 
2.9 
3.4 
4.7 
2.8 
2.0 
2.5 
1.0 
1.0 
0.5 
2.1 
13 
0.4 
0.6 
1.1 
9.1 
0.7 
3.8 
1.0 

Calories. 
195 

365 

Sugar  peas  or  string-peas     .... 

Shelled  kidney  beans 

Shelled  Lima  beans 

335 
740 
570 
465 

620 

Canned  string-beans 

Canned  Lima  beans 

Canned  kidney  beans 

95 
360 
480 
255 

Canned  baked  beans 

600 
2825 

Dried  legumes : 

1625 

1605 

Frijoles     

Lentils 

1695 
1620 
1655 

1590 

1970 

1690 

2560 

St.  John's  bread  (carob  bean)  a    . 

Potatoes 

Cabbage    

Tomatoes 

1565 
385 
145 
105 

1850 

Wheat  breakfast  foods 

Spring-wheat  flour                   .... 

1700 
1650 

Winter-wheat  flour     

Lean  beef              

1650 
730 

840 

Milk 

Cheese 

Eggs       

326 

9150 

720 

a  European  analysis. 

being  grown  in  Europe.  They  form  a  highly  nutritious  food,  but 
the  flavor  is  disagreeable  to  many  persons,  and  they  are  said  to 
produce  indigestion  in  some  instances. 

1  Farmers'  Bulletin  No.  121,  U.  S.  Department  of  Agriculture,  p.  17. 


138 


CLASSES  OF  FOOD 


The  peanut,  although  peculiar  in  its  growth,  is  a  legume  as  well 
as  the  pea  and  bean.  It  differs  chemically  from  the  other  legumes 
in  that  it  contains  a  large  amount  of  fat. 


ROOTS  AND  TUBERS 

Roots  and  tubers  constitute  another  class  of  vegetable  foods  that 
are  of  great  importance.  They  contain  both  starch  and  sugar,  and  to 
these  constituents  is  due  their  chief  value  as  a  food.  On  account  of 
the  small  proportion  of  protein  and  the  large  amount  of  water  they 
contain,  they  are  inferior  in  nutritive  value  to  both  legumes  and 
cereals. 

The  potato  is,  for  several  reasons,  the  most  important  member  of 
the  group.  It  is  a  tuber  or  thickened  underground  stem  of  Solanum 
tuberosum.  It  grows  equally  well  in  a  variety  of  soils,  and  when 
properly  cooked  is  easily  digested.  When  cooked  in  water,  the  salts 
pass  into  the  water,  but  when  cooked  in  their  skins  this  loss  is  largely 
prevented.  By  baking  or  roasting  the  salts  are  best  retained  and  the 
potato  rendered  most  easily  digestible. 

The  sweet  potato  contains  more  water  and  sugar  but  less  starch 
than  the  white  potato.  When  boiled,  it  usually  becomes  mealy,  but 
is  often  converted  into  a  stringy,  sodden  mass  that  is  difficult  of 
digestion. 

The  yam  is  a  tuber  somewhat  resembling  the  potato.  It  is  grown 
and  eaten  chiefly  in  the  tropics,  but  also  in  some  parts  of  Europe. 

The  Dasheen. — This  is  a  plant  of  the  Arace^  family,  growing  in 
the  tropics  and  subtropics.  The  tubers  and  corms  are  used  for  food 
after  the  manner  of  the  potato  and  sweet  potato.  The  corms  may  be 
converted  into  flour  and  used  in  soups  and  gruels.  The  tubers  con- 
tain more  than  50  per  cent,  more  protein  and  carbohydrate  than  the 
potato  and  are  easily  digestible. 

Average  composition  of  edible  portion  of  dasheen  and  other  tropical 

tarch-bearing  roots. 


Water. 

Protein. 

Fat. 

Total  carbohy- 
drates. 

Ash. 

Fuel 

Kind  of  food. 

Sugar, 

starch, 

etc. 

Crude 
fiber. 

value  per 
pound. 

Per  ct. 
66.0 
10.5 
10.5 
10.3 
72.9 
65.7 
70.9 
70.0 
78.3 

69.0 

Per  ct. 
1.1 
.5 
9.1 
1.1 
1.8 
3.0 
1.8 
2.2 
2.2 

1.8 

Per  ct. 
0.2 
.1 
.3 
.2 
.2 
.2 
.2 
.2 
.1 

.7 

Per  ct. 
30.2 

Per  ct. 

1.8 

Per  ct. 
0.7 

.1 
1.1 
1.6 

.9 
1.3 
1.2 

.9 
1.0 

1.1 

Calories. 
610 

88.8 
79.0 

1,625 

1,610 

Cassava  cakes  or  wafers   . 

85.2 
23.3 

28.8 
23.2 
26.1 

18.0 

26.1 

1.6 

.6 

'.S 
.6 
.4 

1.3 

1,605 
475 

605 

475 

530 

Potatoes  for  comparison   . . 
Sweet  potatoes  for  com- 

B80      - 
560 

;i 


VEGETABLE  FOODS 


139 


The  Jerusalem  artichoke  is  commonly  used  in  England.  It  is 
sweet  and  watery,  contains  little  starch,  is  only  slightly  nutritive,  but 
quite  easily  digestible. 

The  beet  contains  a  very  large  percentage  of  starch  and  sugar. 
It  is  raised  extensively  for  the  sugar  industry,  and  is  also  largely 
employed  for  making  salads  to  lend  variety  to  the  diet. 

Carrots,  when  young  and  tender,  form  a  very  nutritious  food,  and 
are  greatly  relished  by  many  persons.  They  contain  from  85  to  90 
per  cent,  of  water. 

Parsnips  when  boiled  long  enough  form  a  good  food ;  like  carrots, 
they  contain  a  large  proportion  of  water  and  a  considerable  amount 
of  sugar. 

Turnips  have  very  slight  nutritive  value,  but  are,  nevertheless, 
very  popular  as  a  vegetable.     They  have  a  tendency  to  cause  flatulence. 

Radishes  are  used  chiefly  to  give  a  relish  to  the  food.  They  con- 
tain little  starch  and  a  large  percentage  of  water. 

The  following  table,  taken  from  Atwater,^  gives  the  average  com- 
position of  the  common  roots  and  tubers: 


Food-materials. 


i 

b 

il 

OS 

o 

1 

8i 

.a 

.a 
< 

Per  ct. 

Perct. 

Perct. 

Perct. 

Perct. 

Perct. 

20 

62.6 

1.8 

0.1 

14.7 

0.8 

20 

55.2 

1.4 

0.6 

21.9 

0.9 

20 

70.0 

1.3 

0.1 

7.7 

0.9 

20 

66.4 

1.3 

0.4 

10.8 

1.1 

30 

62.7 

0.9 

0.1 

6.7 

0.6 

^  D.'O 


Potatoes     .    . 
Sweet  potatoes 
Beets  .... 
Parsnips    .    . 
Tui'nips     .    . 


Calories. 
295 
440 
160 
230 
120 


GREEN  VEGETABLES 

The  green  vegetables  are  valuable  not  only  on  account  of  the  amount 
of  nutriment  present  in  them,  but  for  the  variety  and  relish  they  give 
to  the  diet.  They  contain  a  large  amount  of  salts  and  have  valuable 
antiscorbutic  properties. 

Bryant  and  Milner,  in  a  very  careful  series  of  experiments,^  have 
arrived  at  the  following  conclusions  concerning  the  digestibility  of 
certain  vegetables: 

"So  far  as  sources  of  protein  or  fat  are  concerned,  the  vegetables 
(potatoes,  cabbage,  and  beets)  included  in  these  studies  may  be 
considered  as  of  little  value.  They  do,  however,  contain  carbohydrates 
which  are  well  digested  and  absorbed;  and  they  may  therefore  be 
considered  as  of  value  as  sources  of  energy,  a  large  proportion  of 
which  appears  to  be  available  to  the  body.     The  chief  value  of  many 

1  "  Principles  of  Nutrition  and  Nutritive  Value  of  Foods,"  Farmers'  Bulletin, 
No.   142,  1902,  p.   17. 

2  American  Journalof  Physiology,  1903,  vol.  x.,  No.  2,  p.  81. 


140  CLASSES  OF  FOOD 

vegetables,  however,  is,  perhaps,  aside  from  the  nutriment  or  energy 
they  furnish;  they  add  a  pleasing  variety  and  palatability  to  the 
diet,  supply  organic  acids  and  mineral  salts,  and  give  the  food  a  bulki- 
ness  that  seems  to  be  of  importance  in  its  mechanical  action  in 
maintaining  a  healthy  activity  of  the  alimentary  tract.  Possibly  the 
result  of  these  conditions  is  a  favorable  influence  upon  the  digestion 
of  other  food  eaten  with  the  vegetable." 

Cabbages  contain  a  considerable  quantity  of  sulphur,  and  on  this 
account  are  apt  to  cause  flatulence;  where  digestion  is  good,  however, 
they  are  considered  a  wholesome  form  of  food.  Sauerkraut  is  cab- 
bage prepared  by  placing  salt  between  layers  of  shredded  cabbage 
leaves  and  then  subjecting  the  mass  to  pressure.  This  presses  out 
the  juice,  after  which  acid  fermentation  sets  in.  Owing  to  the  fer- 
mentation it  produces  sauerkraut  is  considered  indigestible. 

Cauliflower  is  the  most  digestible  member  of  the  cabbage  family. 
It  may  be  eaten  either  as  a  salad  or  boiled  and  served  with  a  milk- 
sauce. 

Spinach  is  a  popular  form  of  vegetable  and  is  used  to  a  great 
extent.     It  is  valuable  chiefly  for  its  laxative  efi:ect. 

New  Zealand  Spinach. — Tetragonia  expansa  is  not  a  spinach, 
but  is  grown  to  replace  ordinary  spinach  during  the  hot  summer 
months,  or  in  dry  arid  localities  where  ordinarj^  spinach  does  badly. 

Lettuce  is  the  most  important  representative  of  a  group  of  vegeta- 
bles usually  eaten  raw.  It  is  made  into  salad  and  dressed  with 
vinegar.     The  various  cresses  also  belong  to  this  class. 

Sorrel  is  eaten  chiefly  in  Europe.  It  has  a  peculiar  acid  taste,  due 
to  acid  oxalates,  on  account  of  the  presence  of  which  it  is  to  be  avoided 
by  those  subject  to  gout  or  rheumatism. 

Celery,  which  is  usually  eaten  raw,  is  stringy  and  has  scarcely  any 
nutritive  value.  Cooked  in  milk  it  forms  a  wholesome  and  digestible 
article  of  food. 

Tomatoes  are  eaten  both  raw  and  cooked,  and  are  refreshing,  gen- 
erally liked,  and  easily  digested.  They  are  used  to  flavor  broths  and 
are  valuable  for  canning  purposes,  inasmuch  as  they  retain  their 
flavor  better  than  most  vegetables. 

The  eggplant,  a  close  relative  of  the  tomato,  is  less  digestible, 
especially  when  fried,  than  the  latter. 

Cucumbers  are  eaten  raw,  and  when  young  are  often  pickled  in 
vinegar.     They  are  very  indigestible. 

Asparagus  is  highly  esteemed  for  its  delicate  flavor.  It  is  easily 
digested,  even  by  invalids.  It  has  a  slightly  diuretic  action,  and 
imparts  a  most  offensive  odor  to  the  urine,  which  persists  for  from 
twelve  to  twenty-four  hours. 

Rhubarb,  when  thoroughly  cooked,  is  quite  digestible  and  acts  as  a 
laxative. 


VEGETABLE  FOODS 


141 


Pumpkins  are  used  largely  iu  the  makiug  of  pies,  etc.,  but  they  have 
no  special  food-value. 

Squash,  when  young,  is  quite  digestible. 

Onions,  garlic,  etc.,  are  used  both  as  vegetables  and  as  condiments. 
While  onions  are  used  largely  for  tlavoriug  meat-stews,  salads,  and 
the  like,  they  are  also  eaten  for  their  mildly  laxative  properties. 

The  following  table,  taken  from  Hutchison  (p.  239),  gives  the 
composition  of  the  various  vegetables : 


Cabbage     .    ,    . 
Cabbage,  cooked 
Cauliflower  .    . 
Sea-kale     .    .    . 
Sea-kale,  cooked 
Spinach     .    .    . 
Vegetable  marrow 
Vegetable  marrow, 

cooked 
Brussels  sprouts 
Tomatoes  .    . 
Tomatoes,  cooked 
Greens  .... 
Lettuce  .... 
Lettuce,  cooked 
Leeks     .... 
Celeiy    .... 
Celery,  cooked 
Turnip  cabbage 
Rhubarb    .    .    . 
Macedoine  (tinned) 
Water-cress  . 
Cucumber 
Cucumber,  cooked 
Aspai-agus 
Salsify,  cooked 
Endive  .    .    . 


Red 
Sauerkraut 


la 

1 

It 

Si 

Cellu- 
lose. 

Perct. 

Perct. 

Perct. 

Perct. 

Perct. 

Perct. 

89.6 

1.80 

0.40 

5.8 

1.30 

1.10 

97.4 

0.60 

0.10 

0.4 

0.13 

1.30 

90.7 

2.20 

0.40 

4.7 

0.80 

1.20 

93.3 

1.40 

0.40 

3.8 

0.60 

0.90 

97.9 

0.40 

0.07 

0.3 

0.20 

1.10 

90.6 

2.50 

0.50 

3.8 

1.70 

0.90 

94.8 

0.06 

0.20 

2.6 

0.50 

1.30 

99.2 

0.09 

0.04 

0.2 

0.05 

0.37 

93.7 

1.50 

0.10 

3.4 

1.30 

0.37 

91.9 

1.30 

0.20 

5.0 

0.70 

1.10 

94.0 

1.00 

0.20 

0.1 

0.70 

1.50 

82.9 

3.80 

0.90 

8.9 

3.50 

1.50 

94.1 

1.40 

0.40 

2.6 

1.00 

0.50 

97.2 

0.50 

0.16 

0.5 

0.40 

0.90 

91.8 

1.20 

0.50 

5.8 

0.70 

0.90 

93.4 

1.40 

0.10 

3.3 

0.90 

0.90 

97.0 

0.30 

0.06 

0.8 

0.50 

1.00 

87.1 

2.60 

0.20 

7.1 

1.50 

1.30 

94.6 

0.70 

0.70 

2.3 

0.60 

1.10 

93.1 

1.40 

0.70 

4.5 

1.00 

1.10 

93.1 

0.70 

0.50 

3.7 

1.30 

0.10 

95.9 

0.80 

0.10 

2.1 

0.40 

0.50 

97.4 

0.50 

0.02 

0.7 

0.20 

0.90 

91.7 

2.20 

0.20 

2.9 

0.90 

2.10 

87.2 

1.20 

0.08 

9.0 

0.30 

2.20 

94.0 

1.00 

0.08 

3.0 

0.80 

0.60 

87.0 

3.30 

0.70 

6.0 

1.60 

1.20 

90.0 

1.80 

0.19 

5.8 

0.70 

1.20 

91.0 

1.40 

0.70 

2.9 

1.70 

0.90 

a>   . 
03  A 


Calories. 
165 
165 
175 
175 
175 
120 
120 

120 

95 

105 

105 

275 

105 

105 

150 

85 

85 

145 

105 

110 

110 

70 

70 

110 

110 

110 

110 

110 

110 


Vegetarianism. — Theoretically,  vegetarians  are  supposed  to  sub- 
sist entirely  on  an  exclusive  diet  obtained  from  the  vegetable  kingdom, 
including  vegetables,  cereals,  fruits,  nuts,  etc.,  but  as  a  matter  of 
fact,  many  add  milk,  butter,  eggs,  gravies  and  animal  fats.  The 
disadvantages  of  a  strictly  vegetable  diet  are  too  obvious  to  require 
much  comment.  It  is  possible  to  supply  an  adequate  diet  as  regards 
fats,  proteins  and  carbohydrates  entirely  from  the  vegetable  kingdom 
and  even  to  supply  the  vitamines,  fat  soluble  A  and  water  soluble  B 


142  CLASSES  OF  FOOD 

and  the  proper  amino-aeids,  but  the  danger  of  not  getting  a  sufficient 
diet  in  every  respect  is  so  great  that  a  strict  vegetarian  diet  cannot 
be  recommended  for  any  length  of  time.  This  subject  has  received 
a  large  amount  of  experimental  attention  in  feeding  animals.  Per- 
sons subsisting  on  a  purely  vegetable  diet  for  any  great  length  of 
time  are  apt  to  lose  strength  as  well  as  physical  and  mental  vigor 
and  endurance.  Laborers  are  unable  to  perform  the  same  amount 
of  work  they  could  accomplish  on  a  diet  containing  animal  food. 
While  vegetables  contain  large  proportions  of  protein  in  order  to 
furnish  them  in  sufficient  amounts,  very  large  quantities  have  to  be 
eaten.  This  overfeeding  is  apt,  in  many  instances,  to  produce  diges- 
tive disturbances,  particularly  in  those  suffering  from  gastro-intestinal 
disorders.  A  purely  vegetable  diet,  if  persisted  in,  is  also  said  to 
lessen  the  powers  of  resistance. 

FRUITS  AND  NUTS 
FRUITS 

Fruits  are  of  little  value  as  nutriments,  and  are  useful  mainly  to 
give  variety  to  the  diet.  They  are  used  extensively  as  flavoring 
agents.  The  chief  nutritive  constituent  of  fruits  is  sugar,  and  they 
also  contain  a  small  amount  of  nitrogenous  matters,  cellulose,  starches, 
organic  acids,  and  a  vegetable  jelly  called  pectin,  which  causes  fruit 
to  gelatinize  when  boiled.  The  sugar  present  in  fruit  is  mainly 
fruit-sugar,  or  levulose,  but  some  fruits  contain,  in  addition,  con- 
siderable cane-sugar.  In  general,  fruits  contain  a  large  amount  of 
water,  but  less  earthy  salts  than  other  foods.  The  mineral  elements 
of  fruit  consist  of  potash,  united  with  tartaric,  citric,  and  malic  acid. 
To  these  salts  is  due  the  antiscorbutic  property  of  fruit.  In  addition 
to  this  property  fruits  also  act  as  diuretics,  laxatives,  and  cathartics. 
The  flavor  and  odor  of  fruits  are  due  to  the  presence  of  essential 
oils  and  compound  ethers. 

The  digestibility  of  fruits  varies  with  the  kind  of  fruit  eaten  and 
its  mode  of  preparation ;  stewed  fruits  are  more  easily  digestible  than 
raw  fruits.  Among  the  more  easily  digestible  fruits  are  oranges, 
lemons,  grapes,  and  peaches;  raw  apples,  pears,  and  bananas  are 
somewhat  less  digestible. 

Lemons,  limes,  and  shaddocks,  possessing  similar  properties,  are, 
for  descriptive  purposes,  classed  together.  They  are  valuable  an- 
tiscorbutics, and  have  an  acid,  pungent  flavor  that  may  be  imparted 
to  otherwise  tasteless  foods.  A  cooling  and  refreshing  drink  may  be 
made  from  lemon-juice  diluted  with  water  and  sweetened  with  a  small 
quantity  of  sugar. 

Oranges  are  used  in  invalid  dietaries,  their  juice  allaying  thirst 
very  effectively;  it  can  be  borne  often  by  even  the  most  irritable 
stomach. 


FRUITS  AND  NUTS  143 

Apples  are  wholesome,  digestible,  and  slightly  laxative.  Fresh 
apples  contain  approximately  8  per  cent,  of  sugar  and  85  per  cent, 
of  water,  but  in  drying  two-thirds  of  the  water  is  lost  and  the  sugar 
is  increased  to  about  45  per  cent. 

Pears  are,  as  a  rule,  more  easily  digestible  than  apples,  owing  to 
the  fact  that  their  flesh  is  soft  and  their  skin  not  so  tough. 

Peaches  are  wholesome  and  digestible.  They  contain  less  sugar 
than  most  fruits. 

Bananas  are  the  most  nutritious  of  the  raw  fruits.  The  many 
varieties  differ  in  digestibility  and  in  flavor.  Bananas  are  delicious 
when  baked  or  grilled.  The  flour  which  is  produced  from  dried 
bananas  is  very  easily  digestible. 

Grapes  contain  a  large  amount  of  water  and  considerable  sugar, 
besides  salts  of  sodium,  potassium,  magnesium,  calcium,  and  iron. 
When  thoroughly  ripe  they  are  very  digestible,  and  form  a  useful 
addition  to  the  invalid  diet.  The  habit  of  swallowing  the  skins  and 
seeds  of  grapes  is  most  pernicious,  as  intestinal  irritation  is  often 
brought  about  in  this  way. 

Raisins  are  prepared  by  drying  grapes,  the  white  ones  being  those 
most  used.  They  are  indigestible  unless  well  cooked ;  they  are  usually 
added  to  puddings,  sweetbreads,  etc. 

Plums  and  green  gages  are  quite  digestible  when  fully  ripe. 
They  soon  overripen,  however,  and  then  are  as  harmful  as  when  un- 
ripe. 

Prunes  are  dried  plums.  They  contain  much  sugar  and  are  mark- 
edly laxative  in  their  effect. 

Olives  have  a  bitter  taste,  and  are  eaten  chiefly  as  a  relish  with 
salads.     Their  nutritive  value  is  due  to  the  oil  they  contain. 

Strawberries  are  very  wholesome  unless  taken  in  excess.  They 
are  quite  rich  in  salts  of  sodium,  potassium,  and  calcium,  and  have 
mild  diuretic  and  laxative  properties. 

Currants,  gooseberries,  raspberries,  huckleberries,  mulberries, 
and  a  few  other  berries  contain  considerable  amounts  of  free  acids. 
They  have  slightly  laxative  properties. 

Melons  contain  over  95  per  cent,  of  water  and  about  5  per  cent, 
of  other  constituents;  they  are  considered  indigestible. 

Figs  and  dates  contain  large  quantities  of  sugar.  In  the  eastern 
part  of  the  United  States  they  are  seen  only  in  the  dried  form,  al- 
though in  California,  where  they  are  raised,  they  may  be  obtained 
fresh.     The  value  of  the  date  as  a  food  to  the  Arab  is  well  known. 

The  Alligator  Pear  or  Avocado. — This  nutritive  fruit  has  found 
great  favor  especially  as  a  salad.  It  differs  from  most  fruit  in  that 
it  contains  a  very  large  percentage  of  fat,  averaging  as  much  as  20 
per  cent,  and  some  varieties  even  very  much  more.  It  contains  on 
nv  average,  according  to  Jaffa,  2  per  cent,  of  protein,  7  per  cent,  of 


144 


CLASSES  OF  FOOD 


carbohydrate,  1.2  per  cent,  of  mineral  constituents  and  about  70  per 
cent,  of  water. 

.    The  following  table,  taken  from  Hutchison  (p.  244),  gives  the  com- 
position of  the  various  fruits : 


Apples  .    .    .  . 

Apples,  dried  . 

Pears     .    .    .  . 

Apricots    .    .  . 

Peaches     .    -  . 
Green  gages 

Plums    .    .    .  . 

Nectarines    .  . 

Cherries        .  . 

Gooseberries  . 

Currants    .    .  . 
Strawberries 
Whortleberries 

Blackberries  . 

Kaspberries  -.  . 

Ci^an  berries  .  . 

Mulberries    .  . 

Grapes  .    .    .  . 

Melons  .    .    .  . 

Watermelons  . 

Bananas    .    .  . 

Oiunges         .  . 

Lemons     .    .  . 
Lemon-juice 

Pineapples    .  . 

Dates,  dried  .  . 

Figs,  dried    .  . 

Figs,  fresh     .  . 

Prunes,  dried  . 

Prunes,  fresh  . 

Currants,  dry  . 

Raisins  .    .    .  . 


•6 

S 

o 

a, 

■SI 

Per  ct. 

Perct. 

Per  ct. 

82.50 

0.40 

0.5 

36.20 

1.40 

3.0 

83.90 

0.40 

0.6 

85.00 

1.10 

0.6 

88.80 

0.50 

0.2 

80.80 

0.40 

0.2 

78.40 

1.00 

0.2 

82.90 

0.60 

0.2 

84.00 

0.80 

0.8 

86.00 

0.40 

0.8 

85.20 

0.40 

0.8 

89.10 

1.00 

0.5 

76.30 

0.70 

3.0 

88.90 

0.90 

2.1 

84.40 

1.00 

2.1 

86.50 

0.50 

0.7 

84.70 

0.30 

0.7 

79.00 

1.00 

1.0 

89.80 

0.70 

0.3 

92.90 

0.30 

0.1 

74.00 

1.50 

0.7 

86.70 

0.90 

0.6 

8.93 

1.00 

0.9 

9.00 

1.00 

0.9 

8.93 

0.04 

0.3 

2.08 

4.40 

2.1 

2.00 

5.50 

0.9 

7.91 

1.50 

0.9 

2.64 

2.40 

0.8 

8.02 

0.80 

0.8 

2.79 

1.20 

3.0 

1.40 

2.50 

4.7 

03  r^ 


Per  ct. 
12.5 
49.1 

11.5 

12.4 

6.8 

13.4 

14.8 

15.9 

10.0 

8.9 

7.9 

6.3 

5.8 

2.3 

5.2 

3.9 

11.4 

15.5 

7.6 

6.5 

22.9 

8.7 

8.3 

2.0 

9.7 

65.7 

62.8 

18.8 

66.2 

18.5 

64.0 

74.7 


Per  ct. 

0.4 
1.8 
0.4 
0.5 
0.6 
0.3 
0.5 
0.6 
0.6 
0.5 
0.5 
0.7 
0.4 
0.6 
0.6 
0.2 
O.G 
0.5 
0.6 
0.2 
0.9 
0.6 
0.5 
0.4 
0.3 
1.5 
2.3 
0.6 
1.5 
0.5 
2.2 
4.1 


Per  ct. 

2.7 
4.9 
3.1 
3.1 
3.4 
4.1 
4.3 
4.3 
3.8 
2.7 
4.6 
2.2 
12.2 
5.2 
7.4 
6.2 
0.9 
2.5 
1.0 
LO 
0.2 
1.5 
1.5 
1.5 
1.5 
6.5 
7.3 
7.3 
7.3 
7.3 
1.7 
1.7 


Per  ct. 

1.0 
3.6 
0.1 
1.0 
0.7 
1.0 
1.0 
1.0 
1.0 
1.5 
1.4 
1.0 
1.6 
1.6 
1.4 
2.2 
1.8 
0.5 
0.5 
0.5 
0.5 
1.8 
1.8 
7.0 
7.0 
7.0 
1.2 
1.2 
2.7 
2.7 
2.7 
2.7 


NUTS 

Nuts  contain  a  large  quantity  of  fat  and  a  somewhat  larger  propor- 
tion of  protein.  They  have  but  little  food-value,  and  are  eaten 
mainly  as  a  dessert.     The  average  composition  of  the  nuts  is: 

Water     1-4  per  cent. 

Protein    6-15 

Fats     40-50 

Carbohydrates     6^10         " 


Owing  to  the  large  amount  of  cellulose,  as  well  as  the  large  propor- 
tion of  fat  they  contain,  nuts  are  not  easily  digested.  The  dense 
cellulose  framework  which  makes  nuts  so  indigestible  can  be  destroyed 


FRUITS  AND  NUTS 


145 


by  grindiug,  and  thus  the  nut  made  more  easily  digestible;  such 
preparations  as  Nutrose,  Bromose,  and  Nutmeal,  of  the  Sanitos  Nut 
Food  Company,  are  prepared  in  this  way. 

Almonds  contain  much  fat,  but  no  starch  and  very  little  sugar, 
and  they  are,  therefore,  often  utilized  as  a  bread  for  diabetics. 

Chestnuts  contain  a  small  amount  of  oil  and  a  large  amount  of 
carbohydrates.  They  are  often  eaten  raw,  and  are  quite  indigestible. 
Properly  cooked  they  are  very  digestible. 

Walnuts  contain  a  large  proportion  of  protein  and  fat,  but  are 
quite  indigestible ;  in  some  individuals  they  produce  a  markedly 
laxative  effect. 

The  cocoanut  contains  a  large  amount  of  fat  and  carbohydrate, 
but  is  exceedingly  indigestible. 

The  following  table,  taken  from  Bulletin  No,  122,  United  States 
Department  of  Agriculture,  gives  the  composition  of  nuts  as  com- 
pared with  that  of  other  food-substances : 


Composition  and  fuel-value  of  the 

i 
a 

§ 
3 

edible  portion. 

1 

■3 

J- 

.a 

00 

■d 

a 

w 

^ 

0H 

^ 

0 

< 

C^ 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Peret. 

Per  ct. 

Peret. 

Peret. 

Almonds 

64.8 

35.20 

4.8  1  21.0 

54.90 

17.3 

2.0 

30301 

Brazil  nuts 

49.6 

50.40 

5.3 

17.0 

66.80 

7.0 

3.9 

3329 

Filberts 

52.1 

47.90 

3.7 

15.6 

65.30 

13.0 

2.4 

3432 

Hickory  nuts 

62.2 

37.80 

3.7 

15.4 

67.40 

11.4 

2.1 

3495 

Pecans 

53.2 

46.80 

3.0 

11.0 

71.20 

13.3 

1.5 

3633 

English  walnuts 

58.0 

42.00 

2.8 

16.7 

64.40 

14.8 

1.3 

3305' 

Chestnuts,  fresh 

16.0 

84.00 

45.0 

6.2 

5.40 

42.1 

1.3 

11251 

Chestnuts,  dried 

24.0 

76.00 

5.9 

10.7 

7.00 

74.2 

2.2 

1875' 

Acorns 

35.6 

64.40 

4.1 

8.1 

37.40 

48.0 

2.4 

2718 

Beechnuts 

40.8 

59.20 

4.0 

21.9 

57.40 

13.2 

3.5 

3263 

Butternuts 

86.4 

13.60 

4.5 

27.9 

61.20 

3.4 

3.0 

3371 

Walnuts 

74.1 

25.90 

2.5 

27.6 

56.30 

11.7 

1.9 

31051 

Cocoanut 

48.8 

51.20 

14.1 

5.7 

50.60 

27.9 

1.7 

2986 

Cocoanut,  shredded   .... 

48.8 

100.00. 

3.5 

6.3 

57.30 

31.6 

1.3  ;3125i 

Pistachio  kernels  .... 

48.8 

100.00 

4.2 

22.6 

54.50 

15.6 

3.1  [3010^ 

Pine-nut  or  Pinonpirms  edvlis 

40.6 

5.94 

3.4 

14.6 

6.19 

17.3 

2.8 

3364 

Peanuts,  raw   ....... 

24.5 

7.55 

9.2 

25.8 

38.60 

24.4 

2.0 

25601 

Peanuts,  roasted     

32.6 

67.40 

1.6 

30.5 

49.20 

16.2 

2.5 

3177 

Litchi  nuts 

41.6 

58.40 

17.9 

2.9 

0.20 

77.5 

1.5 

1453 

Beefsteak 

12.8 

87.20 

61.9 

18.9 

18.50 

1.0 

11301 

Wheat  flour 

12.8 

100.00 

12.8 

10.8 

1.10 

74.8 

0.5 

16401 

Potatoes 

20.0 

80.00 

78.3 

2.2 

0.10 

18.4 

1.0 

3851 

1  These  values  were  calculated : 
determined. 
10 


unless  otherwise  indicated  the  fuel-values  were 


146  CLASSES  OF  FOOD 


FUNGI,  ALG^,  AND  LICHENS 

Fungi. — The  three  varieties  of  fungi  usually  eaten  are  the  mush- 
room, truffle,  and  morel. 

Mushrooms  are  prized  chiefly  for  their  agreeable  taste.  They 
possess  some  nutritive  value,  being  rich  in  nitrogenous  matter,  this 
material,  however,  occurring  in  such  form  that  it  is  but  slightly  ab- 
sorbed. They  are  apt  to  produce  gastro-iutestinal  irritation,  aud 
disagree  with  many  persons. 

The  truffle  grows  underground,  and  is  especially  sought  for  on 
account  of  its  delicate  flavor;  the  black  variety  is  considered  the 
finest. 

The  morel  is  usually  obtained  from  France.  It  is  sold  in  the  dried 
state,  and  is  utilized  chiefly  for  seasoning  purposes.  The  following 
table,  by  Konig,  gives  the  composition  of  the  mushroom,  truffle,  and 
morel : 

Mushroom.  Truffle.  Morel. 

Water   91.11  72.80  90.00 

Nitrogenous   matter    2.57  8.91  3.48 

Fat    0.13  0.62  0.24 

Grape-sugar  and  mannite    1.05              0.72 

Other  non-nitrogenous  substances   3.71  7.54  3.95 

Woody  fiber 0.67  7.92  0.67 

Ash     0.76  2.21  0.94 

Many  fungi  are  poisonous,  and  these  are  usually  distinguished  by 
a  disagreeable  odor  and  taste,  and  other  peculiarities  in  structure, 
etc.  Gibson,  who  has  made  a  study  of  edible  fungi,  considers  that 
the  usual  methods  of  distinguishing  between  the  edible  and  poisonous 
varieties  are  very  unreliable.  He  suggests  the  following  as' being  of 
especial  value:  First  avoid  every  mushroom  having  a  cup  or  sug- 
gestion of  such  at  the  base ;  the  distinctly  fatal  poisons  are  thus 
excluded.  Exclude  those  having  an  unpleasant  odor,  a  peppery,  bit- 
ter, or  other  unpalatable  flavor,  and  those  of  tough  consistency.  In 
addition,  it  is  well  to  exclude  those  infested  with  M^orms,  those  in 
advanced  age,  or  partly  decayed,  and  in  testing  new  species  they 
should  be  kept  apart  from  the  others.  The  best  test  is  to  begin  with 
a  piece  the  size  of  a  small  pea,  chew  it  very  slightly,  being  careful  not 
to  swallow  any  of  the  saliva,  and  flnally  expel  all  from  the  mouth. 
If  no  results  follow  during  the  interval  of  a  day  the  experiment  may 
be  repeated,  swallowing  a  little  of  the  juice,  the  fragments  of  the 
fungus  being  expelled  as  before.  In  twenty-four  hours  the  third  trial 
may  be  made,  swallowing  a  small  fragment,  and  if  still  no  unpleasant 
results  follow,  the  following  day  a  piece  the  size  of  a  hazel  nut  may 
be  attempted.  In  using  this  method  poisonous  varieties  may  be  ex- 
cluded with  only  a  temporary  indisposition  on  the  part  of  the  ex- 


SUOAliS  147 

perimentalist,  and  is  the  only  safe  method  of  avoiding  the  poisonous 
varieties.  As  a  rule,  any  mushroom,  omitting  the  Amanita,  which  is 
pleasant  to  taste  and  agreeable  as  to  odor  when  raw,  is  probably 
harmless,  and,  if  an  unfamiliar  species,  may  be  tested  by  the  above 
method.  (For  an  excellent  description  of  the  various  fungi  the  reader 
is  referred  to  Farmers'  Bulletin  No.  15,  United  States  Department 
of  Agriculture.) 

Algae. — The  only  one  of  this  group  that  is  utilized  as  food  is 
Irish  moss.  Its  most  important  constituent  is  lichenin,  a  mucilage. 
It  is  made  into  a  soothing  drink  for  patients  suffering  from  throat 
irritation. 

Lichens. — The  only  important  lichen  used  as  a  food  is  Iceland 
moss.  It  contains  two  carbohydrates:  (1)  lichenin,  a  gelatinous 
substance;  (2)  isolicheniu,  which  resembles  starch.  Iceland  moss  is 
utilized  as  a  food  in  the  Arctic  regions.  It  has  been  made  into  a 
bread  that  has  been  recommended  by  Senator  for  diabetics. 

SUGARS 

Sugars  are  carbohydrates  that  contain  hydrogen  and  oxygen  in  a 
proportion  to  form  water.  Sugar  is  one  of  the  most  valuable  and 
popular  forms  of  food.  This  popularity  is  due  not  only  to  its  nutri- 
tive value,  but  also  to  its  pleasant  taste.  According  to  Abel,^  86 
pounds  of  sugar  per  capita  were  consumed  in  England  in  1895  and 
64  pounds  in  the  United  States  in  the  same  year.  From  7,000,000  to 
8,000,000  tons  are  consumed  annually  in  the  different  countries  of 
the  world.  The  principal  variety  of  sugar  in  use  is  cane-sugar ; 
besides  this,  grape-sugar,  fruit-sugar,  and  milk-sugar  also  enter  into 
the  composition  of  our  foods.  Sugar  is  obtained  in  a  fluid  state,  as 
in  honey,  as  well  as  in  crystalline  form. 

Sugar  is  very  fattening  and  at  the  same  time  is  also  a  great  source 
of  muscular  energy.  The  negroes  working  in  the  sugar  plantations  in 
the  West  Indies  show  the  effect  of  eating  sugar  during  the  harvest 
season ;  they  chew  the  sugar-cane  constantly,  in  consequence  of  which 
their  weight  and  muscular  development  increase  most  remarkably. 
Sugars  and  starch  are  said  to  be  identical  in  nutritive  value,  owing  to 
the  fact  that  both  must  be  converted  into  dextrose  before  they  can 
be  absorbed.  Most  of  the  ill  effects  attributed  to  the  use  of  sugar 
are  due  to  the  fact  that  more  than  one-quarter  of  a  pound  is  consumed 
daily  (Hutchison)  ;  this  amount  may  be  taken  with  impunity  by  the 
healthy  adult,  but  if  more  be  taken,  it  will  be  excreted  rapidly  by  the 
kidneys,  giving  rise  to  a  condition  known  as  temporary  or  alimentary 
glycosuria.  Hutchison  (p.  270)  gives  the  following  figures  as  the 
maximum  amounts  of  the  various  sugars  necessary  to  produce  ali- 
mentary glycosuria : 

1  Farmers'  Bulletin  Xo.  93,  United  States  Department  of  Agriculture,   180f). 


148  CLASSES  OF  FOOD 

For   lactose    120  gm. 

"      cane-sugar    150-200     " 

"      levulose     200     " 

'■      dextrose 200-250     " 

Sugar  can  be  absorbed  only  as  dextrose  and  as  levulose,  all  varieties 
of  sugar  being  converted  into  these  forms  before  they  are  absorbed. 
In  strong  solution  sugar  irritates  the  mucous  membrane  of  the  stomach, 
and  is  apt  to  undergo  fermentation  and  thus  produce  gastro-intestinal 
distress.  Robertson  ^  gives  the  following  table,  arranged  according  to 
the  rapidity  with  which  sugars  are  apt  to  ferment : 


Lactic.  Butyric.  Alcoholic. 

Levulose    (most  fer-  Levulose  (most  fer-  Maltose   (most  fer- 
mentable),                               mentable).  mentable). 

Lactose.  Maltose.  Invert-sugar. 

Dextrose.  Dextrose.  Cane-sugar 

Invert-sugar.  Invert-sugar.  Dextrose. 

Cane-sugar.  Cane-sugar.  Levulose. 

Maltose.  Lactose.  Lactose. 

Cane-sugar  is  the  most  common  and  most  extensively  used  form 
of  sugar.  It  is  made  chiefly  from  sugar-cane  and  from  the  sugar- 
beet.  When  pure,  it  consists  of  a  mass  of  white  crystals.  It  is 
soluble  in  one-half  its  weight  of  cold  water  and  in  even  less  of  hot 
water.  In  order  to  obtain  the  sugar  from  the  cane  the  canes  are 
crushed  and  the  fluid  obtained  treated  with  sulphurous  acid,  neutral- 
ized with  lime,  and  boiled ;  it  is  then  filtered  and  evaporated,  when  the 
sugar  crystallizes  out.  The  sugar  is  still  further  refined  by  remelting 
and  tiltering  through  charcoal. 

Caramel  is  made  by  heating  refined  cane-sugar  to  400°  F.,  when 
it  is  melted  and  browned.  The  resulting  brown  substance  is  called 
caramel.  It  has  a  bitter  taste,  and  is  often  used  as  a  flavoring  agent, 
especially  for  invalid  foods. 

Candy  contains  a  large  amount  of  sugar,  besides  butter  and  other 
fats,  starch,  nuts,  flavoring  extracts,  etc.  The  chief  varieties  of 
candy  are  made  up  largely  of  glucose  and  starch,  colored  with  anilin 
dyes.  Thompson  says :  ' '  Children  assimilate  candy  better  than  adults 
because  they  are  less  liable  to  dyspepsia,  and  because  of  their  rela- 
tively active  muscular  energy  and  relatively  large  body  surface  for 
losing  heat,  in  proportion  to  their  size.  They  do  not,  as  a  rule,  care 
for  fat  meat,  and  prefer  sweets  as  a  natural  substitute."  Contrary 
to  popular  belief,  there  is  no  evidence  to  show  that  candy  produces 
any  injurious  effect  on  the  teeth. 

Molasses,  Treacle,  and  Syrup.— Molasses  and  treacle  are  by- 
products formed  in  the  manufacture  of  cane-sugar.  Molasses  forms 
a  highly  nutritious  food.  On  account  of  the  impurities  it  contains 
molasses  has  a  more  pronounced  aperient  effect  than  refined  syrup. 

1  Edinburgh  Med.  Jour.,  March,  1894. 


SPICES  AXD  COADIMEXTS  149 

Besides  cane-sugar  and  certain  acids,  etc.,  molasses  contains  about  30 
per  cent,  of  invert-su^ar  and  the  same  amount  of  water. 

Hutchison  (p.  264)  gives  the  following  table  showing  the  composi- 
tion of  molasses,  treacle,  and  syrup : 

Molasses.  Treacle.  Syrup. 

Cane-sugar 47.0  32.5  39.0 

Fruit-sugar      20.4  37.2  33.0 

Extractive  and  coloring -matter 2.7  3.5  2.8 

Salts   2.6  3.4  2.5 

Water    27.3  23.4  22.7 

Glucose,  or  grape=sugar,  is  chiefly  made  from  starch  by  inversion 
or  hydrolysis.  It  is  not  nearly  so  sweet  as  cane-sugar,  and  crystallizes 
with  difficulty.  It  is  present  in  small  quantities,  in  combination  with 
other  varieties  of  sugar,  in  most  fruits.  When  taken  in  excess,  glucose 
appears  in  the  urine  unchanged. 

Lactose,  or  sugar  of  milk,  is  the  natural  carbohydrate  for  the 
young,  growing  infant.  It  is  less  abundant  in  cows'  milk  than  in 
human  milk,  and  for  this  reason  it  should  be  added  to  the  milk  of 
bottle-fed  infants. 

Honey  is  sugar  in  a  concentrated  solution.  It  is  made  by  bees 
from  the  nectar  gathered  from  various  flowers.  It  contains  a  crystal- 
lizable  sugar,  resembling  glucose,  and  a  non-crj^stallizable  form. 
Honey  was  formerly  used  as  a  sweetening  agent,  but  cane-sugar,  on 
account  of  its  cheapness  and  abundance,  has  largely  superseded  it. 
Besides  sugar,  honey  contains  wax,  gum,  and  coloring  substances. 

Saccharin  is  used  largely  as  a  substitute  for  sugar  in  cases  of 
rheumatism  and  diabetes.  After  long-continued  use  of  large  quanti- 
ties of  saccahrin  digestive  disturbances  are  apt  to  be  produced. 

Levulose,  or  fruit-sugar,  is  also  utilized  as  a  form  of  sugar  in 
certain  cases  of  diabetes. 

SPICES  AND  CONDIMENTS 

Spices  and  condiments  play  an  important  role  in  increasing  the 
appetite  and  aiding  the  digestive  functions;  they  have  practically  no 
nutritive  value.  By  the  action  of  these  substances  on  the  organ  of 
taste  as  well  as  on  the  mucous  membrane  of  the  stomach  the  appetite 
is  stimulated  and  the  secretion  of  gastric  juice  increased.  In  certain 
gastric  disturbances,  as  well  as  in  diseases  of  the  kidneys,  they  act 
as  irritants  and  should  be  avoided.  Some  spices  act  as  food  preserva- 
tives. 

The  peppers  are  among  the  favorite  spices ;  there  are  two  varieties, 
the  white  and  the  black. 

Mustard. — Mustard  is  used  chiefly  in  salads  or  with  other  foods, 
and  has  a  marked  tendency  to  increase  the  appetite.  There  are  two 
forms  of  mustard:  that  which  is  obtained  from  the  black  mustard 


150  CLASSES  OF  FOOD 

plant  and  that  derived  from  the  white  mustard  plant.  In  large 
quantities  and  diluted  with  water  mustard  acts  as  an  irritant  to  the 
stomach,  producing  nausea  and  vomiting. 

Vinegar  is  produced  from  various  alcoholic  drinks  and  from  fruits. 
It  contains  5  per  cent,  of  acetic  acid.  By  its  action  on  the  cellulose 
of  vegetables  vinegar  softens  the  fiber,  so  that  it  not  only  acts  as  a 
condiment,  but  also  assists  in  the  digestion  of  the  cellulose ;  for  this 
purpose  it  is  added  to  such  vegetables  as  cabbage,  lettuce,  and  cucum- 
bers. 

Horseradish  is  a  condiment  that  is  much  used  with  various  foods; 
it  stimulates  the  flow  of  saliva  as  well  as  of  the  gastric  secretion. 

Sauces,  such  as  tomato,  catsup,  Worcestershire,  and  the  like,  in- 
crease the  appetite  and  give  a  relish  to  certain  foods. 

Spices  act  merely  by  adding  a  flavor  to  foods,  in  this  way  increas- 
ing the  appetite  for  food  that  would  otherwise  be  insipid.  Those  most 
in  use  are  ginger,  cinnamon,  nutmeg,  and  cloves. 

FATS  AND  OILS 

One-fifth  of  the  body-weight  consists  of  fat.  This  is  obtained  in 
part  from  fatty  food  and  in  part  from  the  carbohydrates  and  the 
proteins.  Most  of  the  heat  energy  furnished  the  body  is  supplied  by 
fat ;  it  oxidizes  very  rapidly,  and  in  this  way  spares  the  protein 
elements  that  would  otherwise  be  required  to  furnish  energy.  Fats 
are  digested  in  the  intestine,  where  they  are  emulsified  previous  to 
being  absorbed.  The  most  useful  forms  of  fat  are  cream  and  butter ; 
other  forms  are  bacon  and  cod-liver  oil.  When  eaten  too  liberally, 
fats  are  apt  to  cause  indigestion,  and  when  this  exists,  they  should  be 
taken  only  in  very  restricted  quantities. 

Foods  fried  in  fat  are  indigestible,  and  hot  fats  are  more  indigestible 
than  cold.  Fats  and  oils  have  a  tendency  to  relieve  constipation,  but 
are  counterindicated  in  diarrhea. 

The  most  important  animal  fats  are  butter,  cream,  lard,  suet,  oleo- 
margarin,  cottolene,  butterine,  cod-liver  oil,  and  bone-marrow.  Of 
the  vegetable  fats,  those  most  commonly  employed  are  olive  oil,  cotton- 
seed oil,  linseed  oil,  cacao-butter,  and  the  oils  obtained  from  nuts, 
such  as  cocoanut  oil,  peanut  oil,  and  almond  oil. 

Hydrogenation  of  Oils. — A  method  has  been  discovered  by  which 
hydrogen  may  be  added  to  cheap  vegetable  oil,  converting  them  into 
substances  having  a  close  resemblance  to  the  animal  fats.  Finely 
divided  nickel  oxide  is  used  in  the  process  and  at  present  small 
amounts  of  nickel  may  still  occur  in  these  products,  rendering  them 
undesirable  as  human  foods. 

Indications  for  the  Use  of  Fatty  Foods. — Fatty  foods  are  in- 
dicated especially  in  wasting  disorders  and  in.  convalescence  from 
certain  acute  diseases.     They  are  needed  particularly  in  tuberculosis, 


FATS  AXD  OILS  151 

rachitis,  chronic  bronchitis,  and  chronic  diseases  accompanied  by  the 
formation  of  abscesses. 

There  are  many  proprietary  fatty  foods  on  the  market,  some  of 
which  are  worthy  of  mention.  In  most  of  these  the  fats,  usually  cod- 
liver  oil,  have  been  emulsified ;  this  emulsification  aims  to  make  the  oil 
less  objectionable  to  the  taste  and  also  to  render  it  more  easily  di- 
gestible. 

The  Use  of  Olive  Oil  in  the  Treatment  of  Certain  Diseases. — 
The  external  and  subcutaneous  use  of  olive  oil  will  be  discussed 
further  on.  Chaufford  and  Dupre  were  the  first  to  advocate 
the  use  of  olive  oil  in  the  treatment  of  cholelithiasis.  They  recom- 
mended that  two  doses  of  400  grams  each  be  given  at  half -hour  in- 
tervals, the  patient  being  directed  to  lie  for  three  hours  on  his  right 
side.  The  use  of  olive  oil  in  the  treatment  of  this  condition  has  sub- 
sequently been  advocated  by  "Walker,  Vettsteiner,  and  others. 

Rosenheim  has  advised  the  use  of  olive  oil  in  the  treatment  of 
stricture  of  the  esophagus  due  to  carcinoma.  After  allowing  a  small 
quantity  of  oil  to  flow  into  the  esophagus,  patients  who  were  unable 
to  swallow  before  have  frequently  been  enabled  to  swallow  fluids  and 
semisolids. 

Cohnheim  ^  has  advocated  the  use  of  large  quantities  of  olive  oil 
in  the  treatment  of  certain  forms  of  gastric  disorder.  In  cases  of 
gastric  dilatation  he  usually  administers  the  oil  once  daily,  in  the 
morning  before  breakfast,  in  doses  of  from  100  to  150  c.c. ;  in  those 
instances  in  which  lavage  is  practised  the  oil  is  given  immediately 
after  this  procedure.  After  taking  the  oil  the  patient  is  required  to 
lie  on  his  right  side  for  from  fifteen  to  twenty-five  minutes,  and  is 
not  permitted  to  partake  of  any  food  for  an  hour.  The  oil  is  admin- 
istered warm,  at  about  the  body-temperature.  If,  notwithstanding 
this  procedure,  the  patient  still  continues  to  suffer  pain,  50  c.c.  are 
again  given  at  night,  before  retiring.  Later  Cohnheim  orders  that 
a  wineglassful  be  taken  one  hour  before  breakfast  and  two  dessert- 
spoonfuls from  one  to  two  hours  before  dinner  and  before  supper. 
In  simple  forms  of  ulcer  he  recommends  that  the  olive  oil  be  used 
only  in  the  morning,  and  the  emulsion  of  sweet  almonds  (see  below) 
at  noon  and  night ;  most  patients  do  not  object  to  the  taste  of  the  oil. 
According  to  Cohnheim,  in  those  instances  in  which  the  taste  of  the 
oil  is  objected  to,  this  may  be  overcome  by  taking  a  pinch  of  salt,  a 
swallow  of  brandy,  or  by  allowing  a  peppermint  drop  to  dissolve  in 
the  mouth.  The  oil  treatment  must  be  continued  over  a  period  of 
weeks  or  months.     Cohnheim 's  conclusions  are  as  follows : 

"1.  Cases  of  dilatation  of  the  stomach  due  to  spasm  caused  by  an 
ulcer  or  fissure  at  the  pylorus  are  cured  or  at  least  markedly  relieved 
by  the  use  of  large  quantities  of  oil  (100  to  150  grams). 

"2.  Cases  of  stenosis  of  the  pylorus  due  to  organic  disease  with 

1  Zeitschr.  f.  klin.  Med.,  vol.  lii.,  pts.  1  and  2,  p.  110. 


152  CLASSES  OF  FOOD 

secondary  dilatation  are  also  usually  relatively  cured  by  the  use  of 
large  quantities  of  oil ;  that  is,  these  patients  are  freed  from  dis- 
turbances while  leading  an  abstemious  life.  In  these  cases  the  oil 
acts  mechanically  by  relieving  friction. 

"3.  Cases  of  relative  stenosis  of  the  pylorus  and  duodenum  which 
are  clinically  marked  by  a  continuous  hypersecretion  and  pylorospasm 
several  hours  after  the  principal  meals,  are  much  improved  or  cured 
by  the  oil  treatment. 

"4.  The  pylorospasm  found  in  cases  of  carcinoma  of  the  pylorus  is 
much  diminished  or  relieved  by  the  oil  treatment. 

"5.  Cases  of  ulcer  of  the  pylorus  associated  with  or  without  hyper- 
chlorhydria  are  quickly  cured  by  means  of  the  oil  treatment  or  by 
an  emulsion  of  sweet  almonds. 

"6.  The  oil  is  best  taken  three  times  daily,  half  to  one  hour  before 
meals;  as  a  rule,  it  is  best  to  administer  a  wineglassful  early  in  the 
morning  and  two  dessertspoonfuls  before  dinner  and  supper.  In 
mild  cases  an  emulsion  of  sweet  almonds  may  be  substituted  for  it. 

' '  7.  The  oil  fulfils  three  indications :  it  overcomes  pylorospasm ;  it 
relieves  friction,  and  tends  to  improve  the  general  nutrition. 

"8.  The  oil  acts  as  a  narcotic  in  cases  of  pylorospasm,  producing, 
however,  no  unfavorable  effect — neither  eructations  nor  diarrhea. 

"9.  No  favorable  effect  of  the  oil  treatment  has  been  found  in 
purely  hysteric  gastric  colics. 

"10.  In  that  form  of  gastric  neurosis  manifested  by  pain  when  the 
stomach  is  empty  very  favorable  symptomatic  relief  has  been  ob- 
tained from  the  use  of  olive  oil. 

"11.  A  certain  number  of  cases  of  stenosis  of  the  pylorus  accom- 
panied by  a  consequent  gastrectasia  can  often  be  so  much  relieved  by 
the  oil  treatment  that  no  operative  procedure  need  be  undertaken. 
A  trial  should  be  made  of  the  oil  treatment  in  all  cases  of  stenosis  of 
the  pylorus  before  advising  operative  procedure. 

"12.  The  treatment  prevents  prophylactically  the  production  of 
gastrectasia  and  prevents  relapses  when  utilized  in  favorable  cases." 

Olive  Oil  in  the  Treatment  of  Chronic  Dysentery. — Rutherford  ^ 
gives  his  results  with  olive  oil  in  the  treatment  of  chronic  dysentery. 
According  to  him,  "Upon  the  internal  administration  of  olive  oil 
typical  cases  of  chronic  dysentery  practically  without  exception  show 
changes  in  their  condition  as  follows: 

"1.  Positive  evidence  of  increased  quantities  of  bile  in  the  feces. 

"2.  Decrease  in  the  number  of  daily  bowel  movements  and  marked 
improvement  in  the  character  of  the  same. 

"3.  Gradual  cessation  of  signs  of  fermentation  and  putrefaction 
along  the  intestinal  tract  and  consequent  subsidence  of  pain  and 
tenderness. 

1  American  Medicine,  March,  1904. 


FATS  AyD  OILS  153 

' '  4.  General  systemic  improvement ;  gain  in  appetite ;  repair  of 
digestive  faculties ;  symptoms  of  improved  nervous  system ;  and  rapid 
gain  in  weight  and  strength. 

"5.  Apparent  positive  cure  after  an  average  time  of  two  months 
and  upward,  with  few  recurrences." 

The  method  of  carrying  out  the  treatment  is  as  follows : 

''First  Period. — The  patient  is  given  one  ounce  (30  c,e.)  of  olive 
oil  three  times  a  day  for  the  first  three  days,  when  the  quantity  is 
increased  to  two  ounces  (60  c.c.)  three  times  daily,  and  on  the  sixth 
day  the  same  quantity  is  given  four  times  a  day.  During  the  first 
three  days  the  patient  is  to  be  kept  on  a  milk  diet.  During  the  latter 
half  one  to  three  ounces  (30-90  c.c.)  of  scraped  beef  or  its  equivalent 
of  egg-albumin  will  be  added  daily.  During  this  treatment  a  slight 
loss  in  weight  may  be  temporarily  noticed. 

'"Second  Period. — During  this  period  the  amount  of  oil  is  given 
ill  greater  quantities  (not  less  than  three  ounces — 90  c.c. — three  times 
a  day  without  discomfort  to  the  patient),  and  must  be  kept  up  for 
a  length  of  time  in  severe  and  chronic  cases ;  perhaps  for  two  months 
or  longer,  during  which  period  convalescence  will  have  been  estab- 
lished and  the  weight  regained. 

''Third  Period. — During  this  period  the  patient  is  gradually  re- 
stored to  a  full  diet,  and  the  oil  decreased  in  amount  until  the  ulcers 
have  permanently  healed  and  a  recurrence  not  probable. ' ' 

Blum  first  advocated  the  use  of  olive  oil  by  rectal  injection  for  the 
treatment  of  gall-stone  colic,  and  claims  good  results  from  its  use. 
Fleiner  first  recommended  the  use  of  copious  oil  injections — 400  to 
500  c.c. — in  the  treatment  of  certain  forms  of  chronic  constipation. 
Remarkable  results  are  produced  in  the  spastic  forms  of  chronic 
constipation  when  this  quantity  of  oil  is  injected  two  or  three  times 
weekly.  The  oil  should  be  heated  to  the  body-temperature,  and  in- 
jected high  at  bedtime  and  retained  during  the  night ;  the  same 
precautions  should  be  observed  as  in  giving  nutrient  enemata.  (See 
same.) 

The  Use  of  Emulsion  of  Sweet-almond  Oil  in  the  Treatment  of 
Certain  Gastric  Disorders. — Cohnheim  ^  recommends  an  emulsion  of 
almonds  in  those  cases  in  which  olive  oil  is  not  well  borne.  In  effect 
it  is  identical  to  olive  oil,  previously  described,  relieving  spasm  and 
irritation;  on  the  other  hand,  it  lacks  the  nutritive  value  of  olive  oil. 
On  account  of  its  more  pleasant  flavor  it  is  preferred  by  some.  Cohn- 
heim gives  the  following  directions  for  preparing  an  emulsion  of 
almond  oil:  A  dessertspoonful  of  sweet  almonds  are  blanched  by 
scalding  with  hot  water  and  removing  the  skins ;  after  being  allowed 
to  dry  they  are  ground  into  a  powder  and  placed  in  a  cup  of  boiling 

Zeitschr.  f.  klin.  Med.,  vol.  iii,  Nos.  1  and  2. 


154 


CLASSES  OF  FOOD 


water ;  this  mixture  is  next  rubbed  by  means  of  a  spoon,  and  strained 
through  a  piece  of  gauze ;  a  quantity  equal  to  from  200  to  250  grams 
should  be  obtained  from  a  dessertspoonful  of  almonds.  The  emulsion 
should  be  taken  warmed  and  sweetened  one-half  hour  before  meals, 
in  order  to  relieve  any  irritation  at  the  pylorus  and  to  prevent  spasm 
in  this  portion  of  the  stomach. 

The  various  fats  still  to  be  mentioned  are  butterine,  oleomargarin 
and  bone-marrow. 

Butterine  is  a  fat  prepared  from  beef  and  hog's  fat,  and  is  fre- 
quently used  in  this  country  instead  of  butter;  oleomargarin  is  a 
similar  preparation  made  from  beef  fat.  Both  butterine  and  oleo- 
margarin are  wholesome  fatty  foods,  the  only  objection  against  them 
being  that  they  are  often  sold  fraudulently  for  butter  and  that  they 
do  not  contain  the  vitamins  that  are  in  butter. 

Bone-marrow  is  a  fat  obtained  from  the  large  bones  of  the  ox.  It 
is  used  in  the  treatment  of  tuberculosis  and  in  the  various  forms  of 
anemia,  especially  in  pernicious  anemia.  The  marrow  of  young  ani- 
mals is  usually  preferred.  A  preparation  known  as  the  glycerin 
extract  of  bone-marrow  is  often  utilized. 

SALTS 

The  principal  mineral  constituents  of  the  body  are  the  chlorids, 
phosphates,  sulphates,  carbonates,  fluorids,  and  silicates  of  potassium, 
sodium,  magnesium,  calcium,  and  iron.  lodin  is  present  especially 
in  the  thyroid  gland,  and  the  other  halogens  are  also  found  in  the 
body.  The  amount  of  heat  and  energy  supplied  by  salt  metabolism 
is  so  small  as  to  be  practically  disregarded,  but  the  salts  play  a  most 


Mineral  Matter  Contained  in  the  Urine,  Feces,  and  Sweat  of  Man.     (  Gautier^ 
after  Bischoff,  Voit,  Welisai-g,  Magnier,  and  Lapicque). 


Water    •    •    •    • 
Saline  material 


These  salts  comprise : 

Chlorin 

Phosphoric    anhydrid     (P2O5)     (pent- 

oxid)      

Sulphuric  anhydrid  (SO3)  (trioxid) 
Silicic  anhydrid  (SiOj)  (dioxid)  .  . 
Carbonic  anhydrid  (CO3)  (dioxid)  . 

Potassium  oxid  (KjO) 

Sodium  oxid  (NajO) 

Calcium  oxid  (CaO) 

Magnesium  oxid  (MgO) 

Ferric  oxid  (FcjOj) 


Urine    of    24 
hours. 


Giams' 
1220-1350 
17.3-22 


4.9-7.2 


1.6-3 

1.4-2.26 

0.003-0.004 

0.003-0.004 

1.6-3.1 

4.16-5.9 

0  2.5-0.36 

0.56-0.36 

0.004-0.013 


Fecal  material 
of  24  hours. 


Grams. 
100-119 
4.35-6 


0.015-0.035 

0.76-0.82 

0.06-0.17 

0.17-0.35 

0.05 

0.75-0.30 

0.25-0.35 

0.65-0.70 

0.6.5-0.70 

0.023-0.04 


Sweat   of 
24  hours. 


Orams. 
750-850 
1.6-2.4 


1.12 

Traces. 

0.005 

0.005 

0.005 

0.178 

0.80 

Traces. 

Traces. 

Traces. 


SALTS 


155 


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important  part  in  the  metabolic  process  and  also  maintain  osmotic 

pressure.     They  are  also  essential  to  nervous  and  muscular  reaction. 

The  mineral  salts  taken  in  the  body  in  the  food  are  excreted  in  the 


156 


CLOSES  OF  FOOD 


feces,  the  urine,  sweat,  and  also  in  the  exfoliation  of  epidermis,  the 
hair,  and  the  nails.  The  average  amounts  of  the  various  compounds 
excreted  are  shown  in  the  table  on  page  154. 

The  composition  of  some  of  the  commoner  food  materials  as  regards 
the  salt  content  is  shown  in  the  following  figures  from  Bunge: 

In  100  Parts  by  Weight  of  Dried  Substance  (Bunge). 


KjjO. 

NaaO. 

CaO. 

MgO. 

F2O3. 

P2OS. 

CI. 

Beef 

Wheat 

Potatoes   .... 
White  of  egg  .    . 

Peas 

Woman's  milk 
Milk  of  egg  .    .    . 
Cow's  milk  .    .    . 

1.66 
0.62 
2.28 
1.44 
1.13 
0.58 
0.27 
1.67 

0.32 
0.06 
0.11 
1.45 
0.03 
0.17 
0.17 
1.05 

0.029 
0.065 
0.100 
0130 
0.137 
0.243 
0.380 
1.510 

0.152 

0.24 

0.19 

0.13 

0.22 

0.05 

0.06 

0.20 

0.02 

0.026 

0.042 

0.026 

0.024 

0.003 

0.040 

0.003 

1.83 
0.94 
0.64 
0.20 
0.99 
0.35 
1.90 
1.86 

0.28 

? 
0.13 
1.32 

? 
0.32 
0.35 
1.60 

Ash  analyses  may  be  misleading  as  far  as  phosphoric  and  sulphuric 
acid  are  concerned,  as  they  may  be  artificial  products  from  nuclein- 
containing  substances.  It  will  be  seen  that  animal  food  contains 
relatively  few  bases,  whilst  vegetables  contain  large  quantities  of  the 
alkaline  bases  and  also  phosphoric  acid.  The  alkaline  bases  are, 
however,  always  in  excess. 

The  metabolism  of  the  salts  in  the  body  plays  a  very  important 
part  in  the  physiology  of  nutrition,  and  disturbances  of  this  salt 
metabolism  may  be  the  cause  of  disease.  This  subject  is  as  yet  but 
little  understood,  but  the  therapy  of  the  future  will  undoubtedly 
depend  upon  the  practical  application  of  the  principles  of  nutrition. 
If  the  salts  are  withdrawn  entirely  death  results,  and  Forster  and 
others  have  shown  that  dogs  fed  upon  foods  from  which  the  salts 
had  been  extracted  by  water  die  in  from  26  to  36  days.  If  salts  are 
given  in  excess  they  are  excreted,  but  if  greatly  in  excess,  may  be 
retained  in  the  body  and  cause  untoward  symptoms.  Under  certain 
conditions  even  small  amounts  may  be  retained  or,  on  the  other  hand, 
salts  may  be  excreted  in  such  quantity  in  the  urine  that  they  cannot 
be  held  in  suspension,  and  are  consequently  deposited  in  the  urinary 
tract  and  cause  stone. 

Animal  food  contains  sulphur  and  phosphorous  compounds,  which 
by  oxidation  in  the  body  are  changed  into  sulphuric  and  phosphoric 
acids,  which  tend  to  render  the  blood  and  tissues  acid.  The  destruc- 
tive metabolism  of  the  tissues  of  the  body  tends  toward  the  same  end. 
The  vegetable  foods,  the  cereals  excepted,  contain  large  amounts  of 
alkaline  bases,  which  tend  to  neutralize  the  acids  and  to  render  the 
tissues  alkaline.  A  small  amount  of  the  acids  formed  in  the  metabolic 
processes  is  neutralized  by  the  ammonia  from  the  protein,  and  this 


SALTS  157 

is  excreted  as  ammonium  salts,  and  takes  the  place  of  the  alkaline 
salts  from  vegetable  foods.  The  daily  needs  of  the  body  are  sum- 
marized by  Gautier  as  follows  for  the  average  adult: 

Bases.  Orams.  Acids.  Grams. 

KjO 3.22  P..O5     3.9a 

NasO 7.706  S63    2.03<» 

CaO    1.47  SO,   0.25 

MgO   0.56  CI    8.50« 

Fe,Oj 0.04  CO,    0.05 

{a)  The  food  does  not  in  reality  contain  3.9  grams  of  PoOg  and  the 
2.03  grams  of  sulphur  trioxid  indicated,  but  contains  phosphorus  and 
sulphur,  which  if  reduced  to  the  given  compounds  would  yield  these 
figures. 

(6)  This  comprises  the  amount  of  sodium  chlorid  taken  in  twenty- 
four  hours. 

Alimentary  Alkalis. — The  average  ration  of  110  grams  of  protein 
food  furnishes  about  1  gram  of  sulphur,  about  four-tifths  of  which 
is  oxidized  in  the  body,  and  gives  about  2  grams  of  sulphuric  trioxid, 
SO3.  The  phosphorus  yields  about  0.3  gram  of  phosphoric  pentoxid 
a  day.  To  neutralize  these  it  requires  2.3  grams  of  K^O  or  a  cor- 
responding amount  of  Na.,0.  Bunge  gives  the  following  table  of 
potassium  and  sodium  worth  of  various  foods : 

In  1000  parts  of  dried  substance  the  proportions  are: 
Arranged  according  to  increasing  amount   of  Arranged  according  to  increasing  amounts  of 
potassium.  sodium. 

K2O.       Na^O.  Na=0. 

Rice    1  0.03         Rice   0.03 

Bullock's  blood    2         19  Apples     0.1 

Oats  1  Beans 0.13 

Wheat  c  c       n  1   n  ^    Peas 0.2 

Rye  I 5-6       01-0-4    Oats         , 

Barley       J  Wheat  n  l   n  4 

Dog's  milk    5-6       2-3  Barley     '' u.i   u.4 


Human  milk 5-6  1-2  Rye 

Apples    11  0.1  Potatoes    0.3 

Peas     12  0.2  Human   milk    1.0-2.0 

Milk  of  herbivora 9-17  1-10  Dog's  milk    2-3 

Beef     19  3  Milk  of  herbivora 1-10 

Beans 21  0.1  Beef 3.0 

Strawberries    22  0.2  Bullock's  blood   19.0 

Potatoes    20-28  0.3-0.6 

The  potassium  salts  are  thought  to  be  a  factor  in  exciting  the  action 
of  the  oxidizing  ferments,  but  this  function  is  not  attributed  to  the 
sodium  salts.  The  potassium  salts  form  carbonates,  and  these  meet- 
ing the  sodium  chlorid  in  the  blood  and  tissues,  a  partial  exchange 
takes  place  with  the  formation  of  potassium  chlorid  and  sodium 
carbonate.  The  potassium  salt  is  excreted  in  the  urine,  whilst  the 
sodium  is  set  free  by  the  action  of  the  hydrochloric  acid,  which 
saturates  the  peptones,  or  unites  with  the  sulphuric  or  phosphoric 
acid,  forming  sulphates  or  phosphates,  which  are  excreted  in  the 
urine.     Part  of  the  potassium  salts  goes  to  form  organic  compounds. 


158  CLASSES  OF  FOOD 

A  certain  amount  of  sodium  chlorid  is  constantly  present  in  the  bloody 
and  this  aids  in  the  excretion  of  the  products  of  metabolism.  In- 
creasing the  salts  causes  an  increase  in  the  amount  of  urine  passed^ 
and  this  is  merely  the  means  of  maintaining  the  normal  balance  of 
the  salts.  Increasing  the  amount  of  salt  taken  causes  great  thirst, 
and  may  be  the  cause  of  the  ingestion  of  large  quantities  of  water. 
The  effect  of  hyperchloridation  and  hypochloridatives  in  various 
nervous  diseases  has  been  studied  by  Vincent,  Claude,  and  others. 
In  healthy  individuals  the  complete  withdrawal  of  salt  is  followed 
by  the  appearance  of  certain  symptoms,  chief  of  which  are  lassitude, 
an  incapacity  for  work,  dyspepsia,  and  cramps.  These  symptoms  are 
promptly  relieved  by  restoring  the  usual  allowance  of  salt.  On  the 
other  hand,  a  salt-free  diet  or  a  lowered  salt  allowance  seems  to  have 
a  beneficial  effect  in  some  nervous  diseases,  as  in  epilepsy,  in  which 
disease  it  increases  the  action  of  the  bromids.  It  has  been  suggested 
that  a  salt-free  diet  be  tried  in  hysteria  and  some  of  the  other  func- 
tional nervous  troubles,  as  an  addition  of  12  to  15  grams  of  salt  to 
the  diet  in  hysteria  aggravates  the  condition  very  much,  and  in  latent 
hysteria  may  make  it  manifest.  The  effect  of  a  salt-free  diet  in 
edema  is  noted  in  the  section  on  Nephritis.  Animals  which  feed 
exclusively  upon  meat  do  not  need  salt,  a  fact  pointed  out  by  Bunge. 
The  acids  formed  in  metabolism  in  these  animals  is  neutralized  by 
bases  formed  by  the  breaking  down  of  protein.  Potassium  salts  being 
present  in  vegetables  causes  an  excess  of  potassium  in  the  blood.  In 
order  to  eliminate  this,  as  explained  above,  a  large  amount  of  sodium 
chlorid  is  necessary.  All  graminivorous  animals  need  salt,  and  the 
same  is  true  of  man,  who  is  omnivorous.  The  average  individual  takes 
more  than  there  is  any  necessity  for,  however,  the  taste  for  this  flavor 
leading  to  excesses.  An  average  amount  for  an  adult  is  from  20  to 
30  grams  a  day. 

The  Halogens. — The  elements  chlorin,  iodin,  bromin,  and  fluorin 
are  taken  into  the  body  in  food  or  drink.  The  most  important,  chlorin, 
is  taken  principally  as  sodium  chlorid. 

Iodin  is  found  in  nucleoproteins  and  especially  in  the  thyroid 
gland,  which  contains  0.075  to  0.13  per  cent.  It  is  also  found  in  the 
other  organs.  Gautier  gives  the  following  tables  (after  P.  Bourcet), 
showing  the  iodin  content  of  various  food : 

Iodin  per  Kilogram  of  Fresh  Material. 

Green  beans   0.32  Green  peas    0.80 

Bananas 0.31  Tomatoes 0.23 

Asparagus 0.24  Grapes   0.02-00 

Garlic    0.21  Artichokes 0.017 

White  cabbage  0.21  Pears    0.017 

Mushrooms   0.172  White  dried  beans 0.014 

Strawberries  0.17  Lettuce    0.012 

Rice    0.17  Potatoes    0.01 

Carrots    0.134  Oatmeal  0.009 

Sorrel 012  Wheat  flour    0.007 

Leeks   0.12  Bread  0.000 


SALTS  159 

lodin  per  Kilogram  in  Some  Animal  Foods. 

Gray   shrimp    5.91  Breme    ;  .  1.25 

Crabs   1.82  Fresh  cod 1,32 

Lobster    1.78  Anchovies    0.95 

Smoked  herring 1.57  Tunny,  fresh   0.88 

Fresh  salmon   1.40  Eel    0.80 

Roach  1.38  Whiting 0.31 

Oysters 1.32  Trout   0.08 

Fish,  fruits,  and  starchy  vegetables  manifestly  furnish  most  of  the 
iodin. 

Bromin  is  found  in  the  nuclear  proteins  and  is  excreted  in  the 
sweat.  Foods  which  contain  iodin  also  have  bromin  in  them,  although 
not  in  the  same  quantities.  Fluorin  is  present  in  the  body  and  is 
taken  in  with  the  drinking-water. 

Sulphur. — Sulphur  is  contained  in  both  animal  and  vegetable  pro- 
teins. Four-fifths  of  the  sulphur  taken  is  oxidized  and  excreted  in 
the  urine  either  as  sulphates  or  phenol  sulphates,  the  remainder 
enters  into  compounds  of  more  complex  composition.  About  1  gram 
of  sulphur  is  excreted  daily  by  an  adult. 

Phosphorus. — This  element  is  found  in  the  body  in  large  quanti- 
ties. Voit  has  estimated  that  a  man  weighing  70  kilos  (154  pounds) 
contained  1400  grams  in  the  bones,  130  grams  in  the  muscles,  and  12 
grams  in  the  brain  and  nerves.  It  also  occurs  in  the  body-fluids.  In 
foods  it  is  found  in  the  form  of  the  inorganic  phosphates ;  in  the  form 
of  simple  organic  derivatives  of  phosphoric  acid  and  phosphates 
(phj'tin),  etc.;  in  the  form  of  phosphorized  proteins,  as  nucleo- 
albumin,  etc.  The  body  is  able  to  build  up  complex  phosphorous 
compounds  from,  that  contained  in  the  calcium  phosphate  and  the 
other  components  of  the  body.  Some  studies  have  been  made  of 
phosphorus  metabolism,  particularly  phosphorus  equilibrium.^  Ap- 
parently phosphorus  equilibrium  may  be  maintained  on  various 
amounts  of  phosphorus,  depending  on  the  amounts  habitually  in- 
gested, and  in  this  it  resembles  nitrogen.  Sherman  and  others  have 
determined  that  if  the  phosphorus  is  taken  in  the  foods  in  the  form 
of  the  organic  compounds,  that  equilibrium  may  be  maintained  in 
0.9  grams  of  phosphorus  or  about  2  grams  of  P2O5.  On  a  full  diet 
more  is  required,  and  they  estimate  from  1.5  grams  of  phosphorus 
daily  or  3.5  grams  of  P0O5.  The  Danilevskys  have  shown  that 
lecithin  exerts  a  favorable  influence  on  the  metabolism  of  growing 
animals. 

The  yolk  of  egg  is  the  most  available  and  perhaps  best  form  in 
which  to  increase  the  phosphorous  content  of  the  food.  (See  vita- 
mins.) 

The  table  which  follows  gives  the  data  regarding  the  calcium, 
magnesium,  and  phosphorus  content  of  food  materials. 

1  See  Bulletin  227,  Office  of  Experiment  Station,  United  States  Department  of 
Agriculture. 


160 


CLASSES  OF  FOOD 


Iron. — The  human  body  of  average  size  (65  kilos)  is  supposed  to 
contain  from  3  to  4  grams  of  iron,  chiefly  in  the  hemoglobin  of  the 
blood  and  in  the  chromatin  substance  in  the  nuclei.  The  amount  of 
iron  excreted  daily  as  waste  is  very  small :  in  fasting  0.007  to  0.008 
gram,  and  in  restricted  diets  to  0.0055  to  0.0125  gram.  The  iron 
in  the  food  is  absorbed  from  the  small  intestine,  and  is  distributed 
chiefly  to  the  liver,  spleen,  and  bone-marrow.  After  being  utilized 
the  waste  iron  is  excreted  through  the  walls  of  the  intestine,  and  a 
very  little  by  the  kidneys  and  in  the  bile.  The  iron  used  in  the  body 
is  probably  all  derived  from  the  food,  although  inorganic  iron  un- 
doubtedly is  absorbed  and  is  deposited  and  excreted  much  the  same 
as  the  iron  in  the  food.  The  more  recent  authorities  believe  that 
the  chief  use  of  inorganic  iron  so  often  administered  is  to  stimulate 
the  blood-making  organs.  There  can  be  no  question,  however,  about 
the  advisability  of  administering  iron. 

Approximate  estimates  made  by  Sherman  of  20  American  dietaries 
showed  a  minimum  of  7  milligrams  per  man  per  day  in  a  negro  family 
in  Alabama  to  35  milligrams  in  Maine  lumbermen. 

The  iron  in  the  diet  ordinarily  used  corresponds  nearly  to  the 
amount  of  protein  used.  The  variations  of  the  iron  in  an  ordinary 
diet  containing  100  grams  of  protein  are  from  15  to  20  milligrams. 

Animals  fed  on  diets  poor  in  iron  become  anemic.     Young  animals 

Ash  Constituents  of  Food  Materials — Estimated  Average  Figures  Used  in  Com- 
puting Results  of  Dietary  Studies. 


Food  materials. 


ANIMAL  FOODS,  CKREALS,  ETC. 

Meats     

Fish  and  shellfish 

Eggs 

Butter  ^and  butter:  ne) 

Buttermilk  (estimated  as  milk) 

Cheese 

Cottage  cheese . 

Milk,  condensed* 

Milk,  whole 

Cream 

Barley,  pearled 

Corn  meal . 

Hominy  (as  old  process  meal) 

Oatmeal  (including  rolled  oais,  etc.) 

Rice 

Wheat  flour  (crackers  and  macaroni) 

Ginger  snaps  (assumed) 

Graham  flour  and  entire  wheat  flour  (.assumed) 

Flaked  wheat  breakfast  food         

Bread  used  in  dietary  study  No.  486 

Bread  .  .  

Chocolate 

Molasses 

Maple  syrup     

Honey       


Calcium 
oxid. 


Magnesium  |  Phosphorus 
oxid.  pentoxid. 


Per  cent. 

(1) 

(») 
0.100 

.022 

.172 
1.240 

.100 

.430 

.172 

.147 

.025 

009 

014 

.078 

.012 

.028 

.040 

.037 

.043 

.082 

.021 
141 

.35-5 

.123 

.00.5 


Per  cent. 
(•) 


0.015 


6 
.001 
.018 
.1)49 
.015 
.045 
.018 
.01. 'i 
AW 
.132 
196 
.249 
.060 
.026 
.030 
.150 
.239 
.080 
.019 
.483 
,176 
.100 
.030 


Per  cent. 

(1) 

(") 
0.367 

.031 

.217 
1.490 

.455 

.542 

.217 

.186 

.460 

.458 

.708 

974 

.198 

.216 

250 

6ti0 

.946 

.279 

.162 

.897 

.132 

100 

.065 


1  Meats  were  estimated  to  contain  per   100  grams  protein,   0.076   gram  CaO, 
0.19  gram  MgO,  2.3  grams  P-A- 

2  Fish   and   shellfish   were  estimated   to   contain  per    100  grams   protein,   0.18 
gram  CaO,  0.23  gram  MgO,  2.8  grams  PA- 

3  Estimated  as  equivalent  to  2.5  times  its  weight  of  whole  milk  in  ash  con- 
stituentSi 


SALTS 


161 


Ash  Constituents  of  Food  Materials — Estimated  Average  Figures  Used  in  Com- 
puting Results  of  Dietary  Studies — Continued. 


Food  materials. 


VEGETABLES. 


AsparajBOis 

Beans,  pea,  dried 

Beans,  kidney,  dried , 

Beans,  Lima,  dried , 

Beans,  string,  fresh 

Beets 

Cabbage    

Carrots 

Celery , 

Corn,  canned  or  green 

Cucumbers 

Eggplant 

Greens,  turnip  tops 

Greens,  soup  greens  (assumed)  .  .  .   . 

Horse-radish 

Lettuce , 

Onions 

Parsnips 

Peas,  dried 

Peas,  canned 

Potatoes 

Potatoes,  sweet , 

Pumpkins 

Radishes 

Rhubarb 

Rutabagas       

Spinach 

Tomatoes 

Tomatoes,  canned 

Turnips 

Vegetable  soup  (canned  condensed) 
Water  cresh 


Apples 

Apples,  evaporated . 

Apricots 

Bananas   , 

Blackberries 

Blueberries 

Cherries 

Cranberries 

Currants , 

Currants,  dried ... 

Dates 

Figs,  dried 

Grapes 

Grape  jelly 

Grape  fruit 

Huckleberries  .  .  . 

Oranges 

Peaches,  dried  ... 

Peaches 

Pears 

Pears,  canned  .  .   . 

Pineapples 

Plums 

Plums,  jam,  canned 

Prunes 

Raisins 

Raspberries 

Strawberries  .... 
Watermelons .... 


MISCELLANEOUS. 

Pie,  apple  (assumed) 

Pie,  cream  (assumed) 

Piej  custard  (assumed) 

Pie,  mince 

Pie.  squash 


Calcium 

Magnesium 

Phosphorus 

oxid. 

oxid. 

pentoxid. 

Per  cent. 

Per  cent. 

Per  cent. 

.038 

.017 

.094 

.215 

.252 

1.098 

.226 

.261 

1.235 

.106 

.311 

.752 

.073 

.050 

.091 

.019 

.029 

.095 

.0.58 

.021 

.081 

.077 

.032 

.094 

.094 

.027 

.100 

.045 

.070 

.257 

.028 

.018 

.052 

.017 

.037 

.079 

.508 

.036 

.098 

.080 

.030 

.085 

.136 

.038 

.127 

.045 

.012 

.073 

.040 

.015 

.080 

.076 

.044 

.183 

.137 

.204 

.855 

.023 

.034 

.142 

.016 

.040 

.144 

.025 

.019 

.080 

.032 

.014 

.135 

.U2.5 

.019 

.070 

.060 

.010    • 

.103 

.lOS 

.031 

.129 

.064 

.053 

.103 

.019 

.016 

.045 

.019 

.016 

.045 

.087 

.029 

.107 

.026 

.021 

.106 

.253 

.046 

.066 

Oil 

.014 

.026 

.037 

.054 

.121 

.021 

.019 

.058 

.009 

.035 

.061 

.079 

.037 

.083 

.045 

015 

.046 

.026 

.027 

.075 

.021 

.012 

.034 

.046 

.026 

.070 

.169 

.076 

.178 

.104 

.122 

.280 

144 

.332 

.014 

.019 

.065 

.009 

.015 

.043 

.029 

.015 

.043 

.037 

.027 

.070 

.043 

.016 

.048 

.048 

.093 

.334 

.015 

015 

.049 

.018 

.014 

.041 

.008 

.007 

.020 

.038 

.027 

.022 

.022 

.019 

.038 

.014 

.012 

.025 

.063 

.084 

.204 

.042 

.070 

.240 

.072 

.037 

.093 

.057 

.036 

.068 

.018 

.022 

.034 

.030 

.030 

.100 

.040 

.030 

.150 

.060 

.030 

.200 

.044 

.037 

.191 

.030 

.015 

.150 

thrive  on  milk  which  is  poor  in  iron,  but  this  is  explained  bj^  Bunge. 
who  has  shown  that  the  bodies  of  animals  which  live  upon  milk  contain 
11 


162 


CLASSES  OF  FOOD 


at  birth  a  large  amount  of  iron  which  is  sufficient  to  tide  them  over 
until  they  take  food  richer  in  iron.  Woman's  and  cows'  milk  contain 
approximately  the  same  amounts  of  iron,  but  infants  fed  on  dilutions 
of  cows'  milk  may  become  anemic,  owing  to  the  very  small  amount  of 
iron  taken. 

The  amount  of  iron  derived  from  vegetables  and  fruits  has  not 
received  proper  attention  in  the  past  and  it  should  also  be  borne  in 
mind  that  milling  cereals  lessens  the  iron  content  considerably. 

The  amounts  of  iron  in  various  foods  are  shown  in  the  following 
table  from  Bulletin  185,  Experiment  Station,  United  States  Depart- 
ment of  Agriculture : 


Proportion  of  Iron  in  Food  Materials. 


Food  material. 


Meats 

Fish  and  shellfish 

Eggs,  edible  portion 

Milk 

Cream 

Cheese 

Corn  meal 

Oatmeal  and  other  breakfast 
cereals      

Rice 

Wheat  breakfast  food  used  in 
dietary  study  No.  486  .... 

Wheat  flour,  crackers,  and 
macaroni 

Bread 

Whole-wheat  flour 

Whole-wheat  bread 

Green  vegetables  (asparagus, 
cabbage,  celery,  coUards, 
greens,  lettuce,  onions,  rhu- 
barb)   

Roots  (beets,  carrots,  parsnips, 
radishes,  sweet  potatoes, 
turnips) 

Pumpkins 

Squash  

Beans,  string 

Beans,  Lima,  dried 

Beans,  pea,  dried 


Iron. 


Per  cent. 

(') 

(') 
0.0030 
.00024 
.0002 
.0015 
.00115 

.0036 
.0008 

.00-57 

.0015 
.0010 
.0020 
.0013 


.0008 


.0006 
.0006 
.0006 
.0016 
.0072 
.0067 


Food  material. 


Corn,  canned 

Corn,  dried 

Cucumbers,  as  purchased  .   . 

Peas,  fresh 

Peas,  dried 

Peas,  canned 

Potatoes,  as  purchased .... 

Potatoes,  edible  portion  .  .  . 

Spinach 

Tomatoes,  fresh  or  canned  . 

Vegetable  soup,  canned,  con- 
densed   

Apples,  fresh 

Apples,  evaporated 

Bananas,  edible  portion  .  .   . 

Bananas,  as  purchased  .  .   . 

Grapes 

Lemons,  as  purchased  .... 

Oranges  and  lemons,  edible 
portion 

Prunes,  edible  portion  .  .   . 

Prunes,  as  purchased  .... 

Raisins 

Strawberries 

Canned  and  preserved  fruit, 
jellies,  jam 

Peanuts 

Chocolate 


Iron. 


Per  cent. 
0.0007 
.0029 
.0001 
.0015 
.0056. 
.0008 
.0010 
.00125 
.0030 
.0004 

.0005 
.0003 
.0014 
.0008 
.0005 
.0013 
.0001 

.0002 
.0029 
.0025 
.0036 
.0009 

.0003 
.0020 
.0020 


1  In  meats  0.015  gram  iron  per   100  grams  protein,  and  in   fish  and  shellfish 
0.005  gram  iron  per  100  grams  protein. 


Milligrams  of  Iron  in 

Blood  serum 

White  of  hen's  egg 

Rice     

Pearl  barley    ...    

Wheat  flour  (sifted)    

Cows'  milk 

Human  milk    

Dog's  milk   

Figs 

Raspberries    

Hazelnut  kernels    

Barley     

Cabbage   (inside  yellow  leaves) 

Rye    

Peeled  almonds 


100  Grams  of  Dried  Substance  (Bunge). 

0  Black  clierries,  without  stones       7.2 

Trace        White  beans 8.3 

1.0-2.0      Carrots   8.6 

1.4-1.5      Wheat  bran   8.8 

1.6  Strawberries    8.6-9.3 

2.3  LinsetKl     9.5 

2.3-3.1       Unpeeled   almonds    9.5 

3.2  Red  cherries,   without   stones  10 

3.7  Brown  skinned  halzelnuts  ...  13 
3.9             Apples 13 

4.3  Dandelion  leaves 14 

4.5  Cabbage  (outer  green  leaves)  17 

4.5  Beef 17 

4.9  Asparagus    20 

4.9  Yolk  of  egg  10-24 


.v.i///',s  163 

Milligrams  of  Iron  in  100  Grams  of  Dried  Substance    (Bunge)  —  (Continued) . 

Wheat     5.5  Spinach 3.{-39 

Bilberries   5.7  I'ig's  blood 226 

Potatoes    (i.4  Heniatogen 29U 

Peas    0.2-G.15      Hemaglobin    340 

Manganese.— This  metal  is  found  in  the  body  in  minute  quantities, 
and  small  amounts  are  found  in  some  food  materials.  The  ash  of 
legumes,  asparagus,  caulitiower,  lettuce,  grapes,  and  of  various  grains 
contains  varying  amounts  of  manganese. 

Silica.— This  element  is  eliminated  in  the  hair  and  desquamated 
epithelium.  It  is  present  in  many  vegetables,  but  the  part  played 
in  the  animal  economy  is  unknown. 

Arsenic— Gautier  has  demonstrated  the  presence  of  a  trace  of 
arsenic  in  the  eetodermic  tissues,  the  skin,  hair,  brain,  mammary  gland, 
and  thyroid.  Smaller  traces  have  been  demonstrated  in  other  organs. 
The  role  of  arsenic  in  metabolism  is  unknown.  Traces  of  arsenic 
have  been  found  in  certain  vegetables,  as  cabbage  and  turnips,  as 
well  as  in  some  cereals.  Common  salt  may  contain  some  arsenic,  and 
it  is  sometimes  present  in  foods  either  as  an  adulterant  or  as  a  food 
poison.     (See  same.) 

Calcium  Metabolism. — Calcium  is  taken  into  the  body  in  organic 
forms,  as  in  milk,  yolk  of  egg,  and  cereals,  and  as  inorganic  salts 
chiefly  in  drinking  water,  as  carbonates,  sulphates,  and  phosphates. 
Both  forms  are  absorbable,  but  this  depends  largely  on  what  salts 
are  taken  with  it.  Sodium  chlorid,  for  example,  increases  the  ab- 
sorption, while  the  presence  of  alkalis  decreases  it.  The  minimum 
amount  of  lime  by  which  a  calcium  equilibrium  may  be  maintained 
is  stated  at  from  1  to  ly^  grams  per  day  as  a  standard  for  the  average 
sized  adult.  There  seem,  however,  to  be  great  variations  in  the  quanti- 
ties by  which  a  calcium  equilibrium  may  be  established;  5  to  10  per 
cent,  of  that  taken  is  excreted  in  the  urine,  while  the  remainder  is 
found  in  the  feces,  whether  unabsorbed  or  absorbed,  and  then  elimi- 
nated in  the  intestine.  The  calcium  excretion  in  the  urine  may  be 
increased  by  increase  in  the  ingestion  of  water,  by  the  administration 
of  dilute  hydrochloric  acid,  and  very  largely  increased  by  the  ad- 
ministration of  lactic  acid  and  sodium  lactate.  It  is  also  increased 
in  bodily  rest.  There  is  a  loss  of  lime  over  that  taken  into  the  body 
in  osteomalacia,  in  pernicious  anemia,  in  advanced  tuberculosis  and 
in  diabetes,  and  there  is  a  deficient  excretion,  and  the  lime  is  retained 
in  the  body  in  arteriosclerosis.  If  the  diet  given  is  deficient  in  cal- 
cium, the  loss  will  exceed  the  intake.  If  the  diet  contains  excessive 
amounts  of  calcium,  some  of  the  lime  will  be  retained  in  the  body, 
and  is  apparently  stored  up  in  the  bones,  and  may  not  produce  any 
symptoms.  Foods  particularly  low  in  calcium  content  are  white 
bread,  grapes,  butter,  chicken,  and  roast  beef.  In  the  article  on 
Oxaluria  will  be  found  lists  of  various  foods  with  the  calcium  content 
given. 


1H4  CLASHES  OF  FOOD 

Calcium  Metabolism  and  Tetany. — Stoelzner  has  called  attention 
to  the  fact  that  frank  Oi^-  latent  tetany  can  be  influenced  by  diet,  and 
that  the  administration  of  cows'  milk  causes  an  aggravation  of  the 
galvanic  hyperexcitability  of  the  nerves  and  most  of  the  other 
symptoms.  This  disappears  on  withdrawing  the  milk  and  free  purga- 
tion. Finkelstein  determined  that  this  disturbance  in  nutrition  de- 
pended probably  either  upon  the  assimilation  of  the  phosphates  or 
the  calcium  salts.  Stoelzner,  after  a  study  of  12  cases,  came  to  the 
conclusion  that  this  was  due  to  the  retention  of  the  calcium  salts  due 
to  an  insufficient  elimination.  He  also  called  attention  to  the  fact 
that  tetany,  while  common  in  bottle-fed  babies,  was  very  rare  in  breast- 
fed infants. 

SALT  METABOLISM  AND  DISEASE 

The  tissues  differ  in  their  salt  composition,  and  changes  in  salt 
metabolism  are  probably  due  either  to  atrophy  or  growth  of  certain 
organs  or  tissues,  or  to  their  taking  on  new  functions,  or  to  the 
processes  of  disease.  Studies  of  the  balances  of  the  various  salts 
have  been  made  but  sparingly  in  disease,  and  doubtless  this  subject 
will  be  taken  up  more  energetically  in  the  future.  In  hunger.  Well- 
man  found  that  there  was  a  greater  loss  of  salt  than  could  be  ac- 
counted for  by  the  metabolism  of  the  fleshy  parts.  The  principal 
excess  Avas  phosphoric  pentoxid  and  calcium  and  magnesium  oxid  in 
about  the  same  proportion  as  is  found  in  bone,  and  the  skeletons 
of  the  animals  were  found  to  have  actually  lost  6  or  7  per  cent,  of 
their  weight.  There  is  a  lowered  calcium  excretion  in  many  diseased 
conditions,  among  which  may  be  mentioned,  pleural  effusion,  pneu- 
monia, delirium  tremens,  and  various  fevers.  In  pulmonary  tuber- 
culosis Senator  found  that  there  was  an  excess  of  calcium  excreted. 
In  osteomalacia  the  calcium  balance  is  disturbed,  and  more  is  excreted 
than  is  taken  into  the  body.  Phosphoric  acid  lessens  the '  calcium 
excreted,  and  this  might  be  used  in  experimental  therapeutics. 
Castration,  which  has  been  done  in  a  few  cases,  restores  the  CaOo 
equilibrium,  and  there  is  also  a  tendency  to  restoration  of  the  sulphur 
equilibrium.  On  the  other  hand,  in  myositis  ossificans  the  amount 
of  calcium  excreted  in  the  urine  is  lower  than  normal.  There  is  also 
a  retention  of  lime  salts  in  arthritis  deformans.  In  endarteritis  the 
calcium  excretion  is  interfered  with,  and  Rumpf  claims  to  have 
obtained  good  results  by  giving  salts  which  aid  the  excretion  of 
calcium  as  lactic  acid,  sodium  lactate,  sodium  citrate,  sodium  car- 
bonate, and  sodium  chlorid. 

The  table  on  the  next  page,  by  Hoobler  (Archives  of  Pedriatics, 
March,  1912)  shows  the  mineral  constituents  of  various  common  foods 
expressed  in  percentages  of  the  total  mineral  ash.  This  table  will  be 
found  of  great  practical  use  in  arranging  diets  with  a  view  to  their 
salt  content : 


J 


SALTS 


165 


PHOSPHORUS-CONTAINING  FOODS 


yruits,  15-12  per  cent. 

Berries,  20-13  per  cent. 
Nuts,  43-18  per  cent. 
Cereals,  54-17  per  cent. 


Vegetables,      41-10      per 
cent. 


Milk,  eggs,  cheese,  65-26 

per  cent. 
Meats  and  fish,  48-20  per 

cent. 


Contents  estimated  as  PjOj. 

Pears,  apples,  citron,  cherries,  plums,  apricots,  or- 
anges, tigs. 

Gooseberries,  currants,  huckleberries,  strawberries. 

Almonds,  cocoanuts,  chestnuts. 

Rice  Hour,  rice,  wheat  flour,  buckwheat  flour,  oat- 
meal, oatmeal  flour,  barley  meal,  barley  flour,  rye 
flour,  cornnieal,  cornmeal  flour,  rolled  oats,  pearl 
barley,  macaroni,  brown  bread,  white  bread. 

Black  radishes,  artichokes,  beans,  peas,  lentils, 
pumpkins,  kohlrabi,  cauliflower,  asparagus,  potato, 
cabbage.  Savoy  cabbage,  mushrooms,  onions,  rhubarb, 
cuciunbers,  turnips,  celery,  carrots,  sugar  beets,  rad- 
ishes, spinacli. 

Egg  yolk,  eggs,  cheese,  milk. 

Veal,  pickerel,  pork,  beef,  oysters,  salmon. 


Fruits,  81-35  per  cent. 

Berries,  57-21  per  cent. 
Nuts.  56-28  per  cent. 
Cereals,  38-14  per  cent 


Vegetables,      60-16      per 
cent. 


Milk,  eggs,  cheese,  31-13 

per  cent. 
Meats  and  fish,  48-24  per 

cent. 


POTASSIUM-CONTAINING  FOODS 

Contents  estimated  as  K2O. 

Olives,  plums,  apricots,  figs,  pears,  cherries,  pine- 
apples, citron,  oranges,  apples. 

Huckleberries,  currants,  gooseberries,  strawberries. 

Chestnuts,    cocoanuts,    walnuts,    almonds. 

Rye  flour,  wheat  flour,  cracked  wheat,  rolled  oats, 
cornmeal,  cornmeal  flour,  liominy,  barley  flour,  bar- 
ley meal,  oatmeal,  buckwheat  flour,  oatmeal  flour, 
rice  flour,  graham  bread. 

Potatoes,  rhubarb,  cucumbers,  mushrooms,  cabbage, 
turnips,  celery,  beans,  peas,  tomatoes,  endives,  lettuce, 
carrots,  kohlrabi,  lentils,  radishes.  Savoy  cabbage, 
onions,  artichokes,  asparagus,  cauliflower,  pumpkins, 
blood  beets,  spinach. 


Fruits,  26-7  per  cent. 
Berries,  28-9  per  cent. 
Cereals,  40-14  per  cent. 

Vegetables,  48-7  per  cent. 


Milk,   eggs,   cheese,   31-8 

per  cent. 
Meats  and  fish,  30-8  per 

cent. 


Egg  whites,  milk,  eggs,  cheese. 
Beef,  pork,  veal,  salmon,  pickerel. 

SODIUM-CONTAINING  FOODS 

Contents  estimated  as  NaoO. 

Apples,  oranges,  apricots,  pineapples,  pears,  olives. 

Strawberries,  gooseberries. 

Macaroni,  barley  flour,  brown  bread,  white  bread, 
graham  bread. 

Blood  beets,  spinach,  carrots,  pumpkin,  radishes-i 
asparagus,  tomatoes,  lentils,  endives,  cauliflower,  tur- 
nips, sugar  beets,  artichokes,  lettuce.  Savoy  cabbage. 

Egg  whites,  eggs,  milk. 

Oysters,  pickerel,  salmon. 


Fruits,  2-1  per  cent. 
Berries,  5-1   per  cent. 
Nuts,  1.8-1.3  per  cent. 


IRON-CONTAINING  FOODS 

Contents  estimated  as  Fe^Os. 

Figs,  pineaples.  apples,  pears,  plums. 
Strawberries,   gooseberries,   huckleberries. 
Cocoanuts,  walnuts. 


166 


CLASSES  OF  FOOD 


Cereals,   2-1   per   cent. 


Vegetables, 
cent. 


5.3-1       per 


Rye  flour,  barley  meal,  barley  flour,  rice,  buck- 
wheat flour,  cornmeal,  corn  flour,  rice  flour,  wheat- 
wheat  flour,  graham  flour. 

Lettuce,  onions,  asparagvis,  endfves,  kohlrabi,  pump- 
kins, artichokes,  tomatoes,  lentils,  black  radishes, 
celery,  rhubarb,  potatoes,  mushrooms,  beets. 


SULPHUR-CONTAINING  FOODS 


Fruits,  6  per  cent. 
Berries,  6  per  cent. 
Cereals,  14-13  per  cent. 
Vegetables,  30-5  per  cent. 


Contents  estimated  as  SO3. 

Apples,   pears. 

Gooseberries. 

White  bread,  brown  bread. 

Black  radishes,  mushrooms,  cauliflower,  turnips, 
kohlrabi,  cabbage,  spinach,  carrots,  cucumbers,  pota- 
toes, asparagus,  onions,  celery,  endives,  artichokes. 


CHLORINE-CONTAINING  FOODS 


Fruits,  10  per  cent. 
Nuts,   14  per  cent.    • 
Cereals,  30-5  per  cent. 
Vegetables,  16-5  per  cent. 


Milk,   eggs,    cheese,   28-7 

per  cent. 
Meats  and  fish,  21-5  p.  e. 


Contents  estimated  as  CI. 

Pineapples. 

Cocoanuts. 

White  bread,  brown  bread,  macaroni,  oatmeal. 

Celery,  potatoes,  cucumbers,  radishes.  Savoy  cab- 
bage, lettuce,  asparagus,  tomatoes,  cabbage,  spinach, 
beets,  rhubarb,  turnips,  kohlrabi,  carrots. 

Egg  whites,  milk,  eggs,  cheese. 

Salmon,  oysters,  pickerel. 


MAGNESIUM-CONTAINING  FOODS 

Contents  estimated  as  MgO. 


Fruits,  8-5  per  cent. 


Berries,  6-5  per  cent. 
Nuts,  18-6  per  cent. 
Vegetables,  9-5  per  cent. 

Cereals,  16-5  per  cent. 


Meats  and  fish,  9-5  p.  c.  Salmon,  pork 


Apples,  pineapples,  oranges,  figs,  pears,  citron, 
cherries,  plums. 

Currants,  huckleberries,  gooseberries. 

Almonds,  walnuts,  chestnuts,  cocoanuts. 

Tomatoes,  sugar  beets,  peas,  cauliflower,  kohlrabi, 
lettuce,   spinach,  celery,   carrots,  onions. 

Corn,  cornmeal,  wheat,  wheat  flour,  barley  meal, 
buckwheat,  rice,  rice  flour,  rye  flour,  oatmeal,  rolled 
oats,  graham  bread. 


Fruits,  30-7  per  cent. 

Berries,  14-8  per  cent. 
Nuts,  9-8  per  cent. 
Cereals,  8-7  per  cent. 
Vegetables,  27-5  per  cent. 


Milk,   eggs,   cheese,   35-8 

per  cent. 
Meat  and  fish,  18-7  p.  c. 


CALCIUM-CONTAINING  FOODS 

Contents  estimated  as  CaO. 

Citron,  oranges,  pineapples,  figs,  pears,  cherries, 
olives. 

Strawberries,  gooseberries,  currants,  huckleberries. 

Almonds,   walnuts. 

Oatmeal,  cornmeal,  wheat  flour. 

Savoy  cabbage,  cauliflower,  onions,  lettuce,  rad 
ishes,  celery,  cabbage,  endives,  spinach,  asparagus, 
carrots,  kohlrabi,  turnips,  rhubarb,  artichokes, 
pumpkin,  lentils,  cucumbers,  tomatoes,  beans. 

Cheese,  milk,  egg  yolks,  eggs. 


Oysters,  salmon,  pickerel,  pork. 


BEVERAGES  AND  STIMULANTS 

WATER 

Water  is  the  chief  constituent  of  all  beverages,  and  also  enters 
largelj'  into  the  composition  of  solid  food.  The  human  body  itself 
is  composed  of  about  60  per  cent,  of  water.  While  man  can  live  for 
weeks  without  food,  he  can  abstain  from  water  for  but  a  few  days. 
Water  is  absolutely  necessary  as  a  solvent,  and  as  it  is  constantly 
being  eliminated  by  the  skin,  lungs,  and  kidneys,  this  loss  must  be 
replaced  by  some  means  in  order  to  maintain  the  functions  of  the 
bod3^  This  is  most  conveniently  done  through  the  agency  of  the 
various  beverages.  The  best  method,  however,  of  replenishing  the 
water-supply  is  that  of  drinking  the  water  in  its  pure  state,  M^hen 
it  retains  all  its  solvent  properties.  Some  waters  are  taken  for  their 
laxative  or  purgative  action,  and  others  for  the  salts  which  they  con- 
tain. 

The  amount  of  water  consumed  daily  by  the  average  person  is  from 
six  to  eight  glasses.  This  varies,  however,  with  the  amount  and 
variety  of  food  and  exercise  taken.  The  age,  sex,  and  size  of  the 
individual  and  the  season  of  the  year  also  influence  the  total  daily 
consumption  of  water.  In  very  warm  weather,  for  example,  and 
under  severe  physical  strain,  much  water  that  would  not  be  lost  in 
the  cold  season  of  the  year  is  eliminated  in  the  form  of  perspiration 
and  must  be  compensated  for. 

Water  is  absorbed  chiefly  in  the  intestine ;  a  small  amount  is  ab- 
sorbed in  the  stomach,  and  but  a  very  trifling  amount,  if  any,  in  the 
mouth.  The  water  absorbed  in  the  intestine  is  passed  into  lymphatics, 
and  carried  on  into  the  circulation,  whence  it  is  eliminated.  Thus  by 
removing  the  water  from  the  blood  and  sending  it  through  the  kidneys 
into  the  bladder,  space  is  made  in  the  circulation  for  the  entrance  of 
more  fluid  from  the  alimentary  tract. 

As  previously  stated,  water  is  eliminated  through  the  skin,  kidneys, 
lungs,  and  feces.  The  amount  of  water  excreted  daily  varies  greatly 
under  special  conditions.  In  cold  weather  the  skin  is  inactive  and 
the  kidneys  excrete  a  greater  amount  of  water  than  in  hot  weather, 
when  the  sweat-glands  functionate  more  actively.  When  there  is  a 
tendency  toward  liquid  movements  from  the  bowel,  the  elimination 
by  the  kidneys  is  lessened.  In  warm  weather  elimination  by  the  lungs 
is  stimulated. 

The  temperature  of  drinking-water  is  a  matter  of  some  importance. 
Iced  water  will  stimulate  a  more  rapid  and  a  greater  secretion  of 

167 


168  BEVERAGES  AXD  STIMULAyTS 

gastric  juice,  but  lessens  the  motility  of  the  stomach.  Iced  water 
in  excess  is  injurious^,  and  should  not  be  taken  when  one  is  overheated. 
Hot  water  has  a  very  beneficial  effect  on  an  irritated  stomach, 

AVater  is  a  most  valuable  diuretic  and  diaphoretic.  When  the 
stomach  can  not  retain  it,  it  is  often  given  by  the  rectum.  A  pint  of 
salt  solution,  if  injected  by  the  use  of  a  rectal  tube,  will,  if  the  colon 
has  previously  been  emptied,  be  retained  long  enough  to  be  absorbed. 
If  a  half-pint  or  even  a  pint  of  salt  solution  be  introduced  under  the 
skin,  it  will  be  absorbed  rapidly  and  as  rapidlj^  be  eliminated.  This 
is  one  of  the  most  useful  measures  for  producing  rapid  elimination 
through  the  kidneys. 

According  to  the  amount  of  mineral  water  they  contain  waters  are 
classed  as  hard  and  soft.  Rain-water  is  soft,  and  is  the  purest  form 
of  natural  water.  The  hardness  of  water  is  due  to  earthy  carbonates ; 
hy  boiling,  the  carbonic  acid  gas  is  driven  off  and  the  carbonates  are 
precipitated,  and  the  water  thus  rendered  more  suitable  as  a  beverage. 
Boiling  has  the  additional  advantage  that  it  destroys  most  of  the 
micro-organisms  that  may  be  present  in  the  water. 

"Water  often  contains  impurities,  such  as  lime,  magnesia,  iron,  and 
other  salts,  or  micro-organisms,  and  it  often  becomes  necessary  to 
purify  it  for  drinking  purposes.  Typhoid  fever  and  cholera  are 
communicated  chiefly  through  the  agency  of  polluted  drinking-water. 
The  best  method  of  purification  is  by  distillation,  by  which  means  both 
inorganic  and  organic  impurities  can  be  removed  or  rendered  in- 
nocuous. This  method  is  now  used  largely  on  ships.  When  dis- 
tilled and  aerated,  sea-water  makes  a  most  pleasant  beverage.  Water 
may  also  be  purified  by  means  of  filtration,  charcoal  and  sand  being 
used  extensively  for  this  purpose.  Porcelain  cylinders  are  also  in 
common  use.  Whatever  the  filtering  agent  employed,  unless  it  be 
kept  clean  it  is  liable  to  become  a  source  of  contamination  rather  than 
of  purification.  Owing  to  the  fact  that  soluble  impurities  often  pass 
through  the  filter,  filtered  water  is  not  nearly  so  reliable  as  distilled 
water.  A  very  economic  and  convenient  method  of  purifying  water 
is  to  dissolve  one  gram  of  alum  in  a  little  water  and  pour  this  solution 
into  one  gallon  of  the  water  to  be  purified.  After  standing  for 
twenty-four  hours  the  impurities  will  be  precipitated. 

MINERAL  WATERS 

Mineral  waters  are  frequently  taken  as  substitutes  for  ordinary 
water;  at  times  they  produce  a  most  marked  stimulating  effect  on 
various  organs.  Their  efficiency  is  greatly  enhanced  when  a  "drink- 
ing cure"  is  combined  with  proper  dietetic  regulations.  Mineral 
waters  differ  from  ordinary  waters  in  the  greater  amount  of  gaseous 
and  solid  matters  they  contain.  The  gaseous  constituents  of  mineral 
waters  are  mainly  carbon  dioxid  and  sulphuretted  hydrogen.  The 
solid  constituents  are  salts  of  sodium,  potassium,  magnesium,  alumi- 


WATER  16 'J 

iium  and  calcium,  iron,  iodin,  bromin,  chlorin,  and  sulphur.  Taken 
before  meals,  waters  containing  carbonic  acid  have  a  soothing  effect 
on  an  irritated  stomach.  Taken  in  excess,  all  carbonated  waters  are 
apt  to  produce  indigestion. 

Some  waters  have  a  purgative  effect,  others  a  laxative,  and  still 
others  diuretic.  Thermal  waters  issue  hot  from  springs,  their  virtue 
being  due  to  their  heat.  Some  mineral  waters  have  no  medicinal 
virtue  whatever,  and  are  utilized  merely  as  drinking-water. 

Classification  of  Mineral  Waters. — The  following  classification 
and  description  of  mineral  waters  are  taken  from  Cohen 's  Physiologic 
Therapeutics,  vol.  ix.,  p.  416  (Kisch,  Hinsdale,  and  Peale)  : 


I.     Alkaline  mineral  waters; 


rSiniple  acidulous. 

I  Alkaline  acidulous. 

j  Alkaline  muriated  acidulous. 

I  Alkaline  saline  acidulous. 

{Simple  sodium   chlorid. 
Sodium  chlorid  with  iodin  and  bromin. 
Saline  water  or  brine   (Soolen). 
TIT.     Bitter  waters. 
IV.     Sulphurous  waters. 

r  Carbonated  iron  waters. 
V.     Iron   waters:        <  Sulphurated  iron  waters. 
|_Iron  and  arsenic  waters. 
VI.     Earthy  mineral  waters. 
VII.     Acratothermal  waters. 

I,  Alkaline  Mineral  Waters. — These  waters  are  divided  into:  (1) 
Simple  acidulous  waters;  (2)  alkaline  acidulous  waters;  (3)  alkaline 
muriated  acidulous  waters;  and  {-i)  alkaline  saline-acidulous  waters. 
The  simple  acidulous  waters  are  those  that  contain  large  amounts  of 
carbon  dioxid;  this  ingredient  increases  the  peristaltic  action  of  the 
stomach  and  intestine.  These  waters  are  utilized  largely  ini  the 
treatment  of  minor  gastric  disturbances  and  in  catarrhal  conditions 
of  the  respiratory  tract.  Among  the  most  important  of  these  waters 
are :  Apollinaris  water ;  the  Dorotheenquelle,  at  Carlsbad  ;  the  Geyser 
Spring  in  California;  and  the  JManitou  Soda  Spring  in  Colorado. 

Alkaline  Acidulous  Waters. — These  waters  contain,  in  addition  to 
large  quantities  of  carbon  dioxid,  varying  proportions  of  sodium 
carbonate.  In  moderate  quantities  they  stimulate  the  activity  of  the 
gastro-intestinal  tract,  the  respiratory,  and  the  urinary  organs.  They 
dissolve  mucus  and  neutralize  the  excess  of  acid  in  the  stomach. 

The  folloMang  table  ^  gives  the  chemic  composition  (in  1  liter)  of 
the  most  important  alkaline  acidulous  waters: 

Grams. 

Bilin,  of  sodium  bicarbonate    3.31 

Fachingen,  of  sodium  bicarbonate   3.57 

Neuenahr,  of  sodium  bicarbonate   1.09 

Salzbrunn,   of   sodium   bicarbonate    2.15 

Salvator   Springs,   of   sodium    bicarbonate    0.30 

1  Taken  from  Cohen's  Physiologic  Therapeutics,  vol.  ix.,  p.  420. 


170  BEVERAGES  AXD  STIMULANTS 

Grams. 

Vals,  of  sodium  bicarbonate   7.28 

Vichy,   of   sodium   bicarbonate    4.88 

Bladon    (  Vichy) ,  of  sodium  bicarbonate   0.80 

California  Seltzer,  of  sodium  bicarbonate   0.90 

Idan-ha,   of  sodium   and   magnesium   bicarbonates    .  .  .  .' 1.20 

Napa  Soda    (Pagoda),   of   sodium  and  magnesium   carbonates  and 

bicarbonates    0.70 

Saratoga   ( Vichy ) ,  of  sodium  bicarbonate   1.42 

Saratoga   (Vichy),  of  calcium  and  magnesium  bicarbonates   2.35 

Alkaline  Muriated  Acidulous  Waters. — These  waters  contain,  in  ad- 
dition to  sodium  carbonate  and  carbon  dioxid,  large  quantities  of 
sodium  chlorid.  They  exert  a  markedly  solvent  effect  on  uric  acid, 
and  liquefy  the  secretions  from  the  respiratory  tract.  They  are 
especially  useful  in  catarrhal  conditions  of  the  respiratory  tract,  such 
as  chronic  bronchitis,  and  in  chronic  catarrh  of  the  stomach,  of  the 
biliary  passages,  and  of  the  urinary  organs.  They  are  used  for 
gargling  and  inhalation  purposes,  and  also  for  baths.  To  this  class 
belong  the  waters  of  Royat,  Ems,  Selters,  and  Saratoga  Vichy. 

The  chemic  composition  (in  1  liter)  of  the  most  important  alkaline 
muriated  acidulous  waters  is  shown  by  the  following  table :  ^ 

Sodium  Sodium  Sodium 

carbonate.  bicarbonate.  chloride. 

Grams.  Grams.  Grams. 

^etna     1.2.5  ..  0.41 

Assmannshausen     \.2o  0.13  1..57 

Azule    1.0  0.13  1.56 

Ems     1.0  2.03  1.00 

Gleichenberg    1 .0  2.54  1.85 

Glen  Alpine 1 .0  0.56  0.36 

Luhatsclunvitz     1.0  6.76  4.45 

Radein    1.0  3.01  0.60 

Roisdorf   1.0  1.24  1.84 

Rovat    1.0  1.35  1  73 

Salutaris    1.0  0.08  1.40 

Saratoga  Vichv    1.0  148  2.20 

Selters    * 1.0  1.23  2.33 

Szcawanica    1.0  8.44  4.61 

Weilbach     1.0  1.35  1.25 

Alkaline  Saline  Acidulous  Waters. — These  waters  contain  sulphate 
in  addition  to  bicarbonate  and  chlorid  of  sodium.  They  occur  as 
both  warm  and  cold  waters.  The  cold  waters  possess  a  markedly 
diuretic  effect,  and  when  taken  in  large  quantities  act  as  purgatives. 
The  warm  waters  diminish  the  urinary  secretion.  The  cold  alkaline 
saline  waters  are  useful  in  strong  individuals  for  reducing  flesh  and 
for  the  relief  of  constipation.  The  warm  waters  are  useful  in  gastro- 
intestinal catarrh,  ulcer  of  the  stomach,  gout,  catarrhal  jaundice,  con- 
gestion of  the  liver,  cholelithiasis,  and  in  conditions  associated  with 
urinary  concretions.  Among  this  class  of  waters  are  to  be  mentioned 
Carlsbad,  ^larienbad,  Elster,  Keyser  Spa  in  California.  Castle  Creek, 
Hot  Springs  in  Arizona,  Idaho  Hot  Springs,  and  Manitou  Springs. 

1  lUd.,  vol.  ix.,  p.  422. 


1 


WATER  171 

The  following  table  ^  gives  the  ehemic  composition  of  important 
alkaline  saline  water;  1  liter  of  water  contains: 

Sodium  Sodium  Sodium  Sodium 

At:  sulphate.  carbonate         bicarbonate.       chlorid. 

Grams.  Grams.  Grams.  Grams. 

Aqua  de  Vida  (Lower  Spring)    0.24  0.05  0.05 

Bertritli     0.88  . .  0.72  0.21 

Carlsbad     2.40  ..  1.29  1.04 

Elster    • 5.16  ..  1.68  0.82 

Franzeiifsbad     2.80  ..  0.67  1.14 

Geyser  Spa 0.04  0.08  0.34  0.14 

Manitou    (Manitou  Spring)    0.20  0.02  .  .  0.40 

Marienbad    5.04  .  .  1.82  2.04 

Rohitsch    3.02  . .  1.07  0.07 

Roval   Gorge    (Iron  Duke   Spring)...  0.19  1.24  1.34 

Spi-ingdale  Seltzer    1.74  ..  0.09  0.08 

Tarasp     2.10  ..  4.S7  3.67 

The  chemic  composition  of  the  salts  of  Carlsbad  Sprudel  and 
IMarienbad  Spring  on  complete  evaporation  is  as  follows-  (3  to  5 
grams  (45  to  80  grains)  are  dissolved  in  a  glass  of  water  when  used)  : 

Carlsbad    Sprudel  Marienbad  Spring 

salt.  salt. 

Sodium  sulphate   43.25  per  cent.  54.38  per  cent. 

Sodium  bicarbonate   36.29  "  23.81 

Sodium   chlorid    16.81  "  20.40 

II.  Sodium  Chlorid  Waters. — To  this  class  belong  the  simple 
sodium  chlorid  waters,  sodium  chlorid  waters  containing  iodin  and 
bromin,  and  brine  or  saline  waters. 

Simple  Sodium  Chlorid  Waters. — These  waters  contain,  in  addition 
to  sodium  chlorid  and  other  chlorids,  carbon  dioxid  in  large  quanti- 
ties. Sodium  chlorid  increases  the  secretion  of  the  mucous  mem- 
branes, especially  of  the  stomach.  These  waters  have  a  markedly 
diuretic  and  laxative  effect,  and  are  useful  in  chronic  catarrh  of  the 
respiratory  tract,  and  of  the  stomach,  intestine,  and  biliary  passages. 

The  following  table,^  gives  the  chemic  composition  of  simple  sodium 
chlorid  waters;  1  liter  of  water  contains: 

Ai.  Sodium  chlorid. 

"^''  •  Grams. 

Baden-Baden   2.01 

Bath    0.20 

Bourborne    5.80 

Byron  Springs   (liver  and  kidney)    10. 08 

Byron  Spring  (Byron  Surprise)    304.27 

Carnstadt     2.45 

Congress  Saratoga  Springs   6.49 

Droitwich     310.00 

Glen  wood  Springs   (Yampa)    17.06 

Harrogate     12.70 

1  Cohen's  Physiologic  Therapeutics,  vol.  ix.,  p.  424. 

2  Ibid.,  vol.  ix.,  p.  425. 

3  Ibid.,  vol.  ix.,  p.  429. 


172 


BEVERAGES  AXD  STIMULAMS 


A+.  Sodium  chlorid 

Grams. 

Homburg    9.80 

Kissingen     5.82 

Kronthal    3.54 

Liberty  Hot  Springs   0.33 

Mondorf   8.71 

Pyrmont     7.05 

Seltzer,  at  Saratoga  Springs  4.97 

Soden  in  the  Taurus   3.42 

Upper  Blue  Lick    8.37 

Utah  Hot  Springs   17  05 

^Yiesbaden     6.82 

lodin  and  Bromin  Waters. — These  waters  contain  iodin  and  bromin 
in  addition  to  sodium  chlorid.  The  iodin  occurs  in  the  form  of 
magnesium  iodid,  calcium  iodid,  and  sodium  iodid ;  the  bromin,  in 
the  form  of  sodium  and  magnesium  bromid.  These  waters  increase 
the  activity  of  the  lymphatic  vessels  and  hasten  absorption ;  they  are 
indicated  in  cases  of  scrofula,  syphilis,  and  in  diseases  of  the  glands, 
as  in  goiter.  The  principal  iodin  waters  are  Heilbrunn,  Kreuznach, 
Saratoga  Kissingen  and  ■  Congress. 

The  chemic  composition  of  the  important  iodin  and  bromin  waters 
is  as  follows ;  ^  1  liter  of  water  contains : 

Sodium    Magnesiiim       Sodium  Sodium 

chlorid.         iodid.  iodid.  bromid. 

Grams.        Grams.  Grams.  Grams. 

Champion  Spouting  Spring    12.02              .  .  0.0039  0.0610 

Excelsior    Spring    6.34              .  .  0.070S  0.0610 

Franklin  Artesian  Well    11.28  0.0040  0.0610 

Hall     12.17  0.0420  0.0040  0.0610 

Heilbrunn      4.98  0.0300  0.0040  0.0610 

Ivonitch     8.37  0.0160  0.0040  0.0610 

Krankenheil    0.29  0.0015  0.0040  0.0610 

Kreuznach 10.52  0.0004  0.0040  0.0610 

Lippik    0.61  0.0209  0.0040  0.0610 

Lower  BoAvden    ( Li thia  Spring)    ..  2.13  0.0209  0.0120  0.0610 

Red  Spring   (Tuscan  Spring)    0.35  0.0209  0.0730  2  u.0610 

Salzschlirf     10.24  0.0050  0.0730  0.0610 

Salzbrun    1.90  0.0150  0.0730  0.0610 

Saratoga   (Kissingen  Spring)    5.96  0.0150  0.0006  0.0308 

Wildegg     10.02  0.0300  0.0006  0.0308 

Woodhall   Spa    19.50  0.0075  3  0.0006  0.0200  4 

Zaizon     0.92  0.0010  0.0006  0.0200 

Special  importance  has  been  attached  to  lithium,  which  is  often 
present  in  sodium  chlorid  waters,  and  which  is  believed  to  have  a 
special  effect  in  dissolving  uric  acid.  It  is  very  doubtful  if  such  an 
action  occurs,  yet  these  waters  possess  a  markedly  diuretic  action. 
They  are  useful  in  the  treatment  of  gout,  and  of  renal  and  urinary 
concretions.     Among  the  most  important  simple  sodium  chlorid  waters 

1  Cohen's  Physiologic  Therapeutics,  vol.  ix.,  p.  432. 

2  Iodin. 

3  Potassium  iodid. 

4  Potassium  bromid. 


I 


WATER  173 

may  be  mentioned  those  of  Hamburg,  Baden-Baden,  Kissingen,  Wies- 
baden, Pyrmont,  Byron  Springs  in  California,  Congress,  Excelsior, 
llathorn,  High  Rock,  and  Selzer  at  Saratoga.  Among  the  lithia 
waters  are  Elizabethbrunuen  at  Homburg,  Elster,  Kissingen,  London- 
derry Lithia  Springs,  Geneva  Lithia  Springs,  and  Buffalo  Lithia 
Springs. 

IIL  Bitter  Waters. — These  waters  are  characterized  by  the  large 
proportion  of  sodium  sulphate  and  magnesium  sulphate  which  they 
contain ;  they  also  contain  varied  proportions  of  magnesium  chlorid, 
carbonate,  and  nitrate,  calcium  carbonate,  and  sodium  chlorid.  The 
magnesium  sulphate  acts  as  a  purgative.  These  waters  are  indicated 
in  small  doses  as  stimulants  to  the  intestinal  peristalsis;  they  are 
useful  in  habitual  constipation.  The  principal  springs  belonging  to 
this  class  are  the  Apenta,  Hunyadi  Janos,  Friedrichshall,  Kissingen, 
Crab  Orchard  Springs,  and  Bedford  Springs. 

The  following  table  ^  gives  the  chemic  composition  of  the  most  im- 
portant bitter  waters;  1  liter  of  water  contains: 

Sodium  Magnesium 

sulphate.  sulphate. 

Grams.  Grams. 

Alap     19.14  2.90 

Bedford   Springs    0..5.5 

Birmenstorf    7.00  2.20 

Buda-Pest  bitter  waters:  ,^  .„  ^,  ^r, 

4Denta  1^-*^  ^'*-**^ 

Hunvadi  Janos':::::::::::::;:::' :::  22.56      22.35 

Franz  Josef    23.18  24./  8 

Victoria     33.50  24.19 

Castalian  Mineral  Springs    .  .  11-14 

Crab    Orchard    Springs     (Epsom    or    Folevs 

Springs)     '.  .  l-Ol  35.51 

Friedrichshall    6.05  5.15 

Kissingen  Bitterquelle   5.80  5.00 

Le  Roy   Springs    2.00  5.43 

Mergentheim    6.67  5.43 

Pagosa  Hot  Springs   2.57 

Puellna    9.59  10.85 

Saidschitz     6.09  10.96 

IV.  Sulphurous  Water. — These  waters  contain  hydrogen  sulphid 
or  .some  other  sulphur  compound,  such  as  sodium,  calcium,  magnesium, 
or  potassium  sulphid.  The  sulphurous  waters  are  obtained  both  hot 
and  cold :  they  are  especially  useful  in  the  treatment  of  syphilis  and 
of  chronic  lead-poisoning,  and  in  hemorrhoidal  conditions  and  con- 
gestions of  the  liver.  The  principal  sulphurous  waters  are  the  An- 
derson Sulphur  Springs,  California,  French  Lick  Springs.  Richfield 
Springs,  and  Cold  Sulphur  Springs. 

V.  Iron  Waters. — These  waters  contain  large  proportions  of  iron; 
they  are  divided  into  the  carbonated  iron  waters,  sulphated  iron 
waters,  and  iron  and  arsenic  waters.     The  carbonated  iron  waters 

1  Cohen's  Physiologic  Therapeutics,  vol.  ix.,  p.  435. 


1 


174 


BEVERAGES  AND  STIMULANTS 


contain  large  quantities  of  carbon  dioxid;  these  waters  increase  the 
number  of  the  red  blood-cells  and  the  amount  of  hemoglobin.  They 
stimulate  the  appetite,  but  are  apt  to  produce  constipation.  They 
are  indicated  in  chlorosis  and  in  anemia.  Among  the  principal  car- 
bonated iron  waters  are  those  of  Frauzensbad,  Pyrmont,  Sehwalbach, 
Richfield,  Cresson  (Pa.),  and  Rawley  (Va.). 

The  chemic  composition  of  carbonated  iron  water  is  as  follows ;  ^ 
1  liter  of  water  contains: 


Iron  bicar- 
bonate. 
Grams. 

Bartfeld     0.087 

Bochlet    0.087 

Cresson  Springs 0.085 

Cudowa    0.063 

Elster     0.084 

Franzensbad 0.079 

Immau  0.052 

Iron  Ute  Spring   0.052 

Koenigswart   0.085 

Krynica   0.029 

Liebenstein    0.100 

Marienbad     0. 166 

Ojo  Caliente  0.166 

Owosso  Spring 0.273 

Pacific  Congress  Springs   0.239 

Pyrmont    0.077 

Richfield   Iron   Springs    0.085 

Rock  Enon  Springs    

Sehwalbach   0.080 

Spa 0.070 

Sparta  Artesian   Well    0.010 

Steben    0.060 

Szliacs    0.119 

St.  ^Nloritz   0.035 

Vihnve     0.016 


ron    car- 

Free carbon 

bonate. 

dioxid. 

Grams. 

O.c. 

1683 

,  , 

1505 

1505 

1200 

1266 

1528 

987 

0.057 

987 

0.057 

1163 

0.057 

1513 

0.057 

906 

0.057 

1173 

0.102 

1173 

0.102 

1173 

0.102 

1173 

0.102 

1486 

0.102 

1486 

0.243  2 

1486 

0.243 

1571 

0.243 

304 

0.243 

304 

0.243 

1382 

0.243 

894 

0.243 

1282 

0.243 

337 

Sulphated  Iron  Waters. — These  waters  contain  principally  ferrous 
sulphate,  in  addition  to  sodium,  magnesium,  and  calcium  sulphate. 
Many  of  these  waters  also  contain  arsenic,  alum,  and  sulphuric  acid  in 
small  amounts.  They  are  especially  indicated  in  cases  of  chronic 
diarrhea,  in  anemic  children,  in  chronic  gastric  catarrh,  in  ulcer  of 
the  stomach,  and  in  chronic  malarial  cachexia.  These  waters  should 
be  given  cautiously,  as  at  times  they  produce  indigestion  and  nausea. 
They  are  best  taken  in  small  individual  doses.  Among  the  principal 
sulphated  iron  waters  are  those  of  Sharon  Chalybeate  Spring,  Bedford 
Alum  Spring,  Fauquier  White  Sulphur  Springs,  and  Rockbridge 
Alum  Springs, 

The  table  ^  on  the  next  page  gives  the  chemic  composition  of  the  most 
important  sulphated  iron  waters ;  1  liter  of  water  contains :  ^ 

1  Cohen's  Physiologic  Therapeutics,  vol.  ix.,  p.  444. 

-  Protoxid. 

3  Cohen's  Physiologic  Therapeutics,  vol.  ix.,  p.  445. 


i 


WATER  175 

Iron  sulphate. 
Grama. 

Alexisbad    0.046 

C'lmrcli  Hill  Alum  Springs   2.718 

Kittaniiig  Mineral   fcSpring    0.410 

Mitterbad     0.290 

Muskan     0.190 

Oak  Orchard  Springs   0.565 

Parad    1.100 

Ratzes     0.300 

Ronneby    2.490 

Schuyler   County   Spring    1.197 

Iron  and  Arsenic  Waters. — These  waters  contain  considerable  quan- 
tities of  arsenic  in  addition  to  the  iron;  they  are  indicated  especially 
in  chlorotic  and  anemic  conditions,  in  chronic  malaria,  and  in  neu- 
ralgias. Among  these  waters  may  be  mentioned  Harbin  Hot  Sulphur 
Springs,  Crockett  Arsenic  Lithia  Springs,  and  Swineford  Arsenic 
Lithia  Spring. 

The  following  table  ^  gives  the  chemic  composition  of  the  most 
important  iron  and  arsenic  waters;  1  liter  of  water  contains: 

Iron  sulphate.    Arsenic  acid.  Arsenous  salts. 
Grams.  Grams.  Grams. 

Crockett  Arsenic  Lithia  Springs  .  .  .    0.0006  . .  0.0003 

Gueberquelle    (Srebernik)     0.3700  0.0061  0.0003 

Harbin  Hot  Sulphur  Springs   0.0300  0.0061  0.0050 

Lausigk     4.1800  0.0001  0.0050 

Levioo    2.5600  0.0086  0.0050 

Recoaro     3.2000  0.0039  0.0050 

Roncegno    3.0000  0.1500  0.0050 

VI.  Earthy  Mineral  Waters. — These  waters  are  characterized  by 
the  presence  of  large  amounts  of  calcium  and  magnesium  salts.  They 
diminish  the  production  of  acid  in  the  stomach,  and  also  the  secre- 
tions from  the  respiratory,  digestive,  and  urinary  tracts.  They  are 
indicated  especially  in  chronic  catarrh  of  the  urinary  organs,  in  uric 
acid  diathesis,  gout,  scrofula,  and  rachitis.  In  drinking  these  waters 
small  quantities  should  be  taken  at  first,  and  gradually  increased 
until  the  flow  of  urine  is  markedly  increased.  Among  these  waters 
are  those  of  Contrexeville,  Marienbad,  Wildungen,  Manitou  Springs, 
Mount  Clemens  Mineral  Springs,  Bedford  Springs,  Alleghany  Springs, 
Capon  Springs,  and  Greenbrier  White  Sulphur  Springs. 

The  chemic  composition  of  the  most  important  earthy  mineral 
waters  is  as  follows ;  ^  1  liter  of  water  contains : 

Calcium  Calcium  Calcium 

sulphate.        bicarbonate.         carbonate. 
Grams.  Grams.  Grama. 

Alleghany    Springs    1.80  ..  0.06 

Allonez  Mineral  Springs   1.80  0.42  0.47  3 

Arkansas  Hot  Springs 1.80  0.42  0.12 

Bath     1.50  0.42  0.12 

1  Cohen's  Physiologic  Therapeutics,  vol.  ix.,  p.  447. 
-  Ihid.,  vol.  ix.,  p.  451. 
3  Magnesium  bicarbonate. 


176  BEVERAGES  .i.YZ)  SmiULAyTS 

Calcium  Calcium  Calcium 

sulphate.         bicarbonate.        carbonate. 

Grams.  Grams.  Grams. 

Bedford  Springs  ( Magnesia  Springs )  1.84  0.42                 0.12 

Clifton    Springs    1.18  0.42                  0.16 

Contrexeville    1.10  0.45                  0.16 

Driburg     1.04  1.44                  0.16 

Eaton  Rapid  Wells   0.77-0.94  1.44  0.34-0.78 

Greenbrier   White   Sulphur   Springs  1.33  1.44                 0.12 

Inselbad    0.30  0.12 

Leukerbad    1.42  0.09                 0.12 

Lippspringe    0.82  0.41                  0.12 

Manitou  Springs    0.82  0.41  0.40-1.11 

Marienbad    Rudolfsquelle    0.82  O.GO  0.40-1.11 

Old   Sweet   Springs    0.22  0.60                 0.51 

Szkleno   0.22  0.10                 0.51 

Warm  Sulphur  Springs   0.24  0.10                 0.08 

Weissenburg    0.24  1.27                 0.08 

Wildungen    2.00  1.27                 0.08 

VII.  Acratothermal  Waters.— These  waters,  also  known  as  simple 
or  "inditferent"  waters,  are  characterized  by  the  fact  that  they  are 
obtained  at  a  temperature  of  85°  F.  or  over.  They  do  not,  however, 
contain  any  active  mineral  ingredients.  They  are  rarely  used  for 
drinking  purposes,  but  are  used  mainly  for  thermal  baths.  (For  a 
more  complete  description  of  mineral  waters  and  their  uses  the  reader 
is  referred  to  the  recent  and  most  excellent  volume  on  Balneology  and 
Crunotherapy "  by  Kisch,  Hinsdale,  and  Peale,  in  Cohen's  System 
of  Physiologic  Therapeutics,  vol.  ix.) 

Diet  at  Water  Cures. — Water  cures  should  always  be  carried  out 
at  the  Avatering-places.  Under  exceptional  circumstances  a  water  cure 
may  be  ordered  at  the  patient's  home,  but  the  results  are  never  as 
satisfactory  as  when  the  patient  has  a  change  of  air,  of  scene,  plenty 
of  oiit-door  exercise,  and  freedom  from  care  and  worry.  The  methods 
and  the  diet  vary  greatly  at  different  springs,  and  for  the  most  part 
unnecessarily  so.  Many  of  the  diets  and  methods  are  empiric  and  are 
not  founded  on  any  sound  basis.  Certain  articles  are  forbidden  at 
certain  springs,  often  for  most  fanciful  reasons.  The  routine  and  the 
diet  of  many  springs  is  the  same  for  all  patients,  quite  regardless  of 
the  nature  of  the  disease.  An  important  factor  in  the  failure  of 
water  cures  is  the  abuse  of  water  drinking.  Patients  with  weak 
hearts,  chronic  nephritis,  or  dilated  and  atonic  stomachs  may  easily 
take  more  water  than  can  be  disposed  of,  and  positive  injury  may 
result. 

As  a  rule,  the  water  should  be  taken  in  the  morning  after  rising, 
and  from  200  to  800  c.  cm.  should  be  drunk  slowly,  preferably  whilst 
the  patient  strolls  about.  One-half  hour  should  invariably  elapse 
before  eating,  and  if  large  quantities  of  water  are  taken  one  hour 
should  be  the  shortest  interval  between  the  water  and  food.  Break- 
fast should  be  followed  by  walking  or  other  out-door  amusements  and, 
if  the  patient  is  not  obese  and  requires  it,  half  an  hour  or  an  hour's 


TEA  177 

rest  ma^-  ue  taken  before  and  after  the  midday  ineal.  In  some  cases 
water  is  taken  between  breakfast  and  the  midday  meal. 

The  afternoon  should  be  spent  out  of  doors  if  possible,  and  water 
may  in  some  eases  be  taken  in  the  afternoon,  at  least  half  an  hour 
before  afternoon  tea  or  cotfee.  The  evening  meal  should  be  light 
and  taken  not  later  than  seven  o'clock,  and  the  patient  should  be  in 
bed  by  nine  o  'clock.  Care  should  be  taken  not  to  disturb  too  radically 
the  habits  of  the  old  and  infirm,  as  by  so  doing  often  more  harm  than 
good  may  result. 

The  diet  ordered  will,  of  course,  depend  upon  the  nature  of  the 
disease.  In  general,  it  may  be  stated  that  the  diet  should  be  that 
which  the  patient's  condition  calls  for,  and  not  the  more  or  less  arbi- 
trary diet  of  the  particular  spring  which  the  patient  visits.  Healthy 
individuals  may  take  the  strict  cures  if  they  so  desire,  and  often  find 
the  change  interesting  and  feel  better  for  the  mental  effect  so  pro- 
duced. In  a  general  way  the  diet  cures  at  watering-places  forbid 
meats  difficult  of  digestion,  as  fat  or  salt  pork,  smoked  meats,  fat 
sausage,  pate  de  foie  gras,  sardines,  lobsters,  eels,  and  the  like,  and 
certain  vegetables  are  usually  on  the  forbidden  list,  as  cabbage,  young 
potatoes,  old  peas,  truffles,  mushrooms,  unripe  and  overripe  or  stale 
fruit,  berries  in  some  places,  nuts  as  well  as  all  very  highly  seasoned 
and  complicated  dishes,  cheese,  et'C. 

In  general,  all  strong  alcoholic  beverages  are  forbidden,  but,  as  a 
rule,  light  wine  or  beer  is  allowable  in  small  quantities  if  the  patient 
can  be  trusted  not  to  take  to  much.  Coffee  and  tea  are  usually  al- 
lowed in  moderate  quantities,  but  chocolate  or  cocoa  may  be  sub- 
stituted in  most  instances  when  they  are  contraindicated,  or  some  hot 
gruel  or  substitute  for  coffee  may  be  taken.  Smoking  is  usually 
forbidden,  but  this  rule  is  very  frequently  broken.  The  advice  of  an 
enlightened  physician  at  the  cure  is  very  valuable. 

Besides  water,  there  are  a  number  of  beverages  that  serve  not  only 
to  meet  the  physical  needs  of  the  body,  but  are  also  taken  to  produce 
a  stimulant  effect.  They  also  serve  the  purpose  of  a  stimulant  where 
such  is  necessary  from  time  to  time,  as  in  the  case  of  disease.  The 
habit  of  using  beverages,  either  for  the  purpose  of  relieving  fatigue 
or  for  conviviality,  is  most  pernicious,  as  it  is  apt  to  induce  a  habit 
for  taking  such  drinks,  which  in  time  leads  to  excesses.  We  shall 
now  take  up  in  order  the  other  beverages — tea,  coffee,  cocoa,  and  the 
various  alcoholic  stimulants. 

TEA 

Tea  is  a  preparation  made  from  the  leaves  of  an  evergreen  plant 
known  as  Thea.  It  is  grown  in  China,  Japan,  India,  Ceylon,  and  in 
North  Carolina.  There  are  many  varieties  of  the  plant,  and  the 
flavor  of  tea  varies  with  its  source  and  the  variety  of  the  plant. 
There  are  two  great  classes  of  teas,  the  green  and  the  black,  the 
12 


178  BEVERAGES  AND  STIMULANTS 

distinction  between  the  two  being  due  to  the  method  of  preparation. 
Several  times  during  the  year  the  plant  sends  out  young  shoots,  which 
are  picked  as  often  as  they  appear.  Black  tea  is  prepared  by  exposing 
the  fresh  leaves  to  the  rays  of  the  sun;  after  they  have  become  with- 
ered the  constituents  are  liberated  by  rolling  and  breaking  up  the 
fibers  and  cells  of  the  leaf.  The  broken-up  leaves  are  then  collected 
and  allowed  to  ferment  while  still  moist;  during  this  process  the 
tannic  acid  is  rendered  less  soluble  while  the  essential  oils  are  in- 
creased. After  again  exposing  them  to  the  sun  the  leaves  are  dried  in 
an  oven.  In  the  process  of  preparing  green  tea  the  Chinese  ' '  wither ' ' 
the  leaves  in  pans  at  a  temperature  of  160°  F. ;  the  Japanese  steam 
them.  The  fluid  principles  are  then  liberated  by  breaking  up  the 
leaves;  finally  they  are  again  withered,  sweated  in  bags,  and  slowly 
roasted.  The  chief  difference  between  black  and  green  tea  lies  in 
the  fact  that  black  tea  is  fermented  while  green  is  not.  As  in  the 
process  of  fermentation  the  tannic  acid  becomes  less  soluble,  black  tea 
contains  much  less  tannic  acid  than  green  tea.  The  following  table, 
from  Bannister,^  gives  the  composition  of  black  and  of  green  tea : 

Black  tea.  Green  tea. 

Water    8.20  5.96 

Caffein  3.24  2.33 

Albumin    (insoluble)    17.20  16.83 

Albumin    (soluble)    0.70  0.80 

Alcoholic  extract 6.79  7.05 

Dextrin    0.50 

Pectin  and  peetic  acid  •. 2.60  3.22 

Tannic  acid    16.40  27.14 

Chlorophyll  and  resin 4.60  4.20 

Cellulose    34.00  25.90 

Ash    6.27  6.07 

Tea  has  practically  no  nutrient-ingredients.  Its  principal  con- 
stituents are  caffein  and  tannic  acid,  and  its  special  aroma  is  due  to 
a  volatile  oil.  It  owes  its  stimulating  effect  to  the  presence  of  caffein. 
As  the  action  of  tannic  acid  is  detrimental  to  the  process  of  diges- 
tion, tea  should  be  so  prepared  as  to  contain  as  large  a  proportion  of 
caffein  as  possible  and  the  smallest  possible  amount  of  tannic  acid. 

When  the  leaves  are  placed  in  boiling  water,  caffein  is  extracted 
very  rapidly.  Tannic  acid,  however,  is  much  less  soluble;  it  follows, 
therefore,  that  in  order  to  have  as  little  tannic  acid  in  the  tea  as 
possible,  the  leaves  should  be  boiled  in  water  for  as  short  a  time  as 
practicable.  To  prepare  the  infusion  pour  boiling  water  on  the  tea- 
leaves  and  allow  the  mixture  to  stand  where  it  will  keep  hot,  though 
not  boil,  for  from  three  to  five  minutes.  Water  used  in  preparing 
tea  should  not  be  hard  or  stale. 

When  the  tannic  acid  which  tea  contains  occurs  in  large  quantities, 
the  pepsin  of  the  gastric  juice  is  precipitated ;  in  weaker  solutions  tea 

1  Cantor  Lectures,  1890. 


COFFEE  179 

retards  digestion.  For  these  reasons  tea  is  not  a  suitable  beverage 
for  persons  suffering  from  gastric  disturbances.  Among  the  more 
prominent  symptoms  of  excessive  tea-drinknig  are  gastric  disorders 
cardiac  distress,  and  a  variety  of  nervous  symptoms,  such  as  ex- 
citability, sleeplessness,  and  muscular  incoordination. 

COFFEE 

Coffee  was  introduced  into  Europe  in  the  same  century  as  tea,  and 
only  a  few  years  later.  It  is  prepared  from  the  seeds  of  Cofffa 
arahica,  which  was  originally  grown  in  Arabia,  but  has  since  been 
cultivated  in  Java,  Ceylon,  Costa  Rica,  and  Brazil.  The  fruit  of  the 
plant,  which  has  the  appearance  of  a  cherry,  when  opened  discloses 
the  coffee-bean.  In  order  to  prepare  the  beans  for  use  they  are  dried 
at  a  high  temperature  and  then  roasted  and  ground.  In  roasting, 
one-fifth  of  the  caffein  and  one-tenth  of  the  fat  present  are  lost.  The 
aroma  of  coffee  is  due  to  the  presence  of  caffeol,  an  oil  liberated  in 
roasting.  According  to  Hutchison  (p.  310),  a  cup  of  black  coffee 
contains  about  as  large  a  quantity  of  tannic  acid  and  caffein  as  a  cup 
of  tea.  Coffee  is  often  adulterated,  chicory,  acorns,  and  other  sub- 
stances being  added  for  this  purpose.  The  adulteration  may  not  be 
injurious  in  its  effect,  but  alters,  sometimes  even  agreeably,  the  flavor 
of  the  coffee. 

In  gouty,  nephritic  and  arterio-sclerotic  patients  it  may  be  desirable 
to  omit  coffee  from  the  dietary  on  account  of  the  large  quantities  of 
caffein  bodies  which  this  beverage  contains.  There  are  two  prepara- 
tions however  from  which  a  large  portion  of  the  caffein  has  been  ex- 
tracted, i  e.,  Dekofa  and  Kaffee-Hag,  to  which  this  objection  does 
not  hold,  if  taken  in  moderation.  Dekofa  contains  about  0.13  caffein 
and  Kaffee-Hag  only  0.03  per  cent. 

Preparation  of  Coffee. — In  order  to  obtain  coffee  of  the  finest 
flavor,  the  beans  should  be  roasted  and  ground  shortly  before  they  are 
to  be  used,  as  the  flavor  is  impaired  by  exposure  to  the  air  after 
grinding.  The  water  should  have  reached  the  boiling-point  before 
it  is  poured  over  the  coffee.  The  pot  should  then  be  placed  for  a  few 
moments  in  a  hot  place,  but  boiling  must  not  be  allowed  to  continue, 
or  the  aroma  will  be  lost  and  the  coffee  contain  too  large  a  percentage 
of  tannic  acid. 

The  effect  of  coffee  on  the  system  is  that  of  a  stimulant,  due  to 
the  caffein  present;  it  acts  directly  on  the  cerebral  centers,  stimulates 
the  heart,  and  deepens  the  respirations.  It  is  an  excitant  of  the 
nervous  system,  and  in  some  persons  produces  nervousness,  excitabil- 
ity, and  insomnia;  in  others  it  acts  as  an  agreeable  stimulant.  In 
persons  suffering  from  dyspepsia  it  has  a  tendency  to  disturb  diges- 
tion. It  lessens  the  strain  of  fatigue,  and  soldiers  frequently  depend 
upon  its  stimulating  effect  during  long  marches. 


180 


BEVERAGES  AXD  STIMULANTS 


The  following  table,  taken  from  Bannister's  Cantor  Lectures,  gives 
the  composition  of  raw  and  of  roasted  coffee: 


CafFein 

Saccharine  matter 

Caffeic  acids 

Alcoholic  extract  (nitrogenous  and  color- 
ing-matter)      

Fat  and  oil 

Legumin 

Dextrin 

Cellulose  and  insoluble  coloring-matter    . 

Ash 

Moisture 


Mocha. 


Raw.      Roasted. 


1.08 
9.55 
8.46 

6.90 
12.60 
.9.87 

0.87 
37.95 

3.74 

8.98 


0.82 
0.43 
4.74 

14.14 

13.59 

11.23 

1.24 

38.62 

4.56 

0.63 


East  ludiau. 


Raw       Roasted. 


1.11 

8.90 
9.58 

4.31 
11.81 
11.23 

0.84 
38.60 

3.98 

9.64 


1.05 
0.41 
4.52 

12.67 

13.41 

13.13 

1.38 

47.42 

4.88 

1.13 


COCOA 

Cocoa  was  introduced  into  Europe  long  before  either  coffee  or  tea. 
It  is  prepared  from  the  seeds  of  the  cacao  tree,  Theohroma  cacao. 
The  seeds  are  contained  in  a  pulpy  fruit,  somewhat  resembling  a 
cucumber,  from  which  the}'  are  extracted.  The  fruit  is  gathered 
into  heaps  and  allowed  to  ferment,  when  the  pulp  becomes  loosened. 
Durinu'  this  process  the  seeds  become  dark  and  lose  some  of  their 
bitterness.  They  are  then  roasted,  by  which  process  they  are  broken 
into  bits,  constituting  the  so-called  "cocoa  nibs."  A  decoction  of 
cocoa  nibs  is  made  by  boiling  the  seeds  in  water  for  several  hours  and 
removing  the  residue  by  straining.  Cocoa,  as  ordinarily  prepared,  is 
made  by  grinding  the  seeds  into  a  paste,  to  which  sugar  or  starch 
is  added ;  if  starch  is  used,  the  cocoa  is  boiled  for  a  few  minutes,  but 
if  sugar  is  added,  the  cocoa  only  requires  the  addition  of  boiling 
water  or  milk. 

Theobromin,  the  chief  alkaloid  present  in  cocoa,  occurs  in  amounts 
of  from  1  to  2  per  cent.  Cocoa  also  contains  nitrogenous  substances, 
15  per  cent.;  tannic  acid,  5  per  cent.;  starch,  5  to  15  per  cent.;  fat, 
known  as  cocoa-butter,  45  to  50  per  cent. ;  mineral  constituents,  2  to 
3  per  cent. 

Theobromin,  while  a  stimulant,  is  less  apt  to  induce  nervous 
symptoms,  such  as  sleeplessness  and  palpitation,  than  either  tea  or 
coffee.  By  reason  of  the  large  proportion  of  sugar  and  fat  contained 
in  it,  however,  when  used  in  excess,  cocoa  is  likely  to  produce  in- 
digestion. When  not  too  rich,  it  forms  a  nutritious  drink  especially 
useful  for  children  and  for  convalescents. 

The  table  on  the  next  page,  taken  from  Ewell,^  gives  the  chemic 
analysis  of  various  cocoa  preparations. 

Chocolate  is  prepared  by  adding  starch,  sugar,  and  such  flavoring 

1  Allen's  Commercial  Organic  Analysis,  vol.  iii,  p.  2. 


ALCOHOL 


181 


Fry's  cocoa  extract  .  . 
Schmitzer's  cocoatuia  .  . 
Van  Houten's  cocoa  .  . 
Blooker's  Dutch  cocoa  . 
Rountree's  cocoa  extract 
Rountree's  powdered 

chocolate 

Epp's  prepared  cocoa  .  . 
Fry's  diamond  sweet 

chocolate 

London  cocoa  (unknown 

maker) 

Chocolat-Menier  .    .    .    . 


Fat. 


Fiber 

Cane- 

3.89 

3.70 

4.38 

3.76 

4.42 

Ash. 


Added  starch. 


30.95 
31.13 
29.81 
31.48  i 
27.56  ! 


25.84     1..30   \     51 
25.94  i    1.51    I     26 


4.24    None. 
6.33       " 
8.64  i      " 
6.06  I      " 
8.48 


1.66 
3.15 


18.60  \   0.81    !     55     I  1.16 


11.13 
21.13 


2.13 
1.10 


32 
58 


2.82 
1.40 


Very  little  arrow  root. 
Much  arrow-root. 
Much  wheat-stanli  and 
some  arrow-root. 

Much  arrow-root. 
None. 


substances  as  vanilla  to  cocoa.  It  contains  1.5  per  cent,  of  theobromin, 
15  per  cent,  of  fat,  5  per  cent,  of  nitrogenous  substances,  and  about 
60  per  cent,  of  sugar. 

In  addition. to  their  stimulating  effect,  cocoa  and  chocolate  possess 
a  marked  nutrient  value  not  possessed  by  either  tea  or  coffee. 

The  kola  nut  possesses  properties  similar  to  those  of  cocoa.  It 
contains  an  alkaloid,  caffein,  thein,  or  theobromin. 

ALCOHOL 

Alcohol  is  produced  by  the  fermentation  of  sugars  with  yeast,  and 
the  principal  constituent  in  all  alcoholic  beverages  is  ethyl  alcohol, 
although  other  constituents  may  modify  the  action  of  various 
beverages  so  that  the  effect  produced  is  not  always  exactly  the  same. 
The  glucose  contained  in  fruits  is  fermented  directly  into  alcohol, 
whereas  the  starches,  in  such  substances  as  potatoes,  grains,  etc..  are 
converted  into  dextrin  and  maltose,  and  then  by  the  aid  of  diastatic 
ferments,  before  the  alcoholic  fermentation  can  take  place,  they  are 
converted  into  glucose. 

Alcohol  has  a  food  value  of  7  calories  per  gram,  and  the  law  of  the 
conservation  of  energy  obtains  with  the  alcohol  diet  just  as  with  the 
ordinary  diet,  and  the  energy  of  the  alcohol  oxidized  in  the  body  is 
transformed  completely  into  kinetic  energy  and  appears  either  as 
heat,  or  as  muscular  work,  or  both.  To  this  extent,  at  any  rate,  it 
is  used  like  the  energy  of  protein,  fats,  and  carbohydrates.  The  fat 
protection  following  the  use  of  alcohol  is  very  slightly  different  from 
that  of  ordinary  food,  and  it  apparently  protects  the  body  fat  ([uite 
as  effectively  as  do  the  fats  and  carbohydrates  for  which  it  is  sub- 
stituted. The  power  of  alcohol  to  protect  the  protein  of  food  or  body 
tissue,  or  both,  from  consumption  has  been  clearly  demonstrated  by 
Atwater.  Its  action  in  this  respect  appears  to  be  similar  to  that  of 
the  carbohydrates  and  fats,  and  in  this  way  alcohol  serves  the  body 
as  food.  In  some  cases  it  is  apparently  equal,  and  in  others  inferior, 
to  fat  and  carbohydrate,  but  it  is  by  no  means  certain  that  these 
latter  are  always  equal  to  each  other  in  this  power.     At  times  it 


182  BEVERAGES  AAD  STIMULANTS 

seems  to  exert  a  special  action,  and  in  large  quantities  is  positively 
toxic  and  may  retard,  or  even  prevent,  metabolism  in  general,  and 
protein  metabolism  in  particular.  On  the  other  hand,  in  small  doses 
it  seems,  at  times,  to  have  an  opposite  influence,  tending  to  increase 
disintegration  of  protein.  This  action,  though  not  conclusively 
demonstrated,  is  very  probable,  and  thus  afi:*ords  a  satisfactory  ex- 
planation for  the  occasional  failure  of  alcohol  to  protect  protein. 
Atwater  states  that  the  only  justilication  for  calling  alcohol  a  protein 
poison  is  found  in  this  disintegrating  tendency.  This  action  appears 
to  be  temporary  and  most  liable  to  occur  in  people  little  accustomed 
to  its  use,  and  the  circumstances  under  which  it  occurs  cannot  be 
fully  defined.  In  moderate  quantities  alcohol  produces  no  considera- 
ble increase  in  the  amount  of  heat  radiated  from  the  body,  but  in 
large  quantities  it  causes  a  dilatation  of  the  vessels  of  the  skin,  in- 
creases the  circulation  through  the  vessels  near  the  surface,  and  thus 
increases  heat  radiation. 

The  question  of  alcohol  as  a  source  of  muscular  energy  is  one  of 
considerable  interest.  It  would  seem,  from  Atwater 's  experiments, 
that  it  contributes  its  share  for  muscular  work,  but  its  desirability  as 
a  part  of  the  diet  for  muscular  work  must  be  decided  not  on  this  fact 
alone,  but  on  the  effect  of  the  alcohol  on  the  character  of  work. 
Alcohol  has  a  favorable  action  on  the  performance  of  muscular  work 
both  when  the  muscles  are  vigorous  and  when  they  are  exhausted, 
and  this  effect  is  seen  almost  immediately  after  the  administration, 
but  lasts  for  a  very  short  time  and  is  succeeded  by  a  paralyzing  action. 
This  later  paralyzing  action  overbalances  the  primary  stimulating 
effect,  so  that  the  sum  total  of  the  amount  of  work  done  with  alcohol 
is  less  than  that  done  without  it.  Similar  depressing  effects  are  not 
seen  to  follow  the  use  of  tea,  coffee,  or  kola.  In  practical  tests  with 
the  use  of  alcohol  in  the  diet  of  people  engaged  in  muscular  labor  it 
seemed  to  prove  that  the  subjects  work  to  a  slightly  better  advantage 
with  ordinary  rations  than  with  those  containing  alcohol. 

Atwater  found  that  the  effect  of  alcohol  in  small  quantities  is  slightly 
to  increase  the  digestibility  of  proteins,  but  not  to  alter  the  digestibil- 
ity of  other  nutrients,  that  is,  carbohydrates  and  fats.  At  least  98 
per  cent,  of  alcohol  ingested  is  oxidized  in  the  body,  whereas  ordinarily 
98  per  cent,  of  carbohydrates,  95  per  cent,  of  fats,  and  93  per  cent,  of 
proteins  are  oxidized.  The  rapidity  with  which  alcohol  is  absorbed, 
and  the  ease  with  which  it  is  oxidized,  make  it  a  valuable  adjunct  in 
feeding  individuals  in  extreme  wasted  conditions,  as  in  prolonged 
fevers. 

Quite  as  important  as  Atwater 's  experiments  on  the  nutritive  value 
of  alcohol  is  the  valuable  review  of  Abel  on  the  Pharmacologic  and 
Physiologic  Action  of  Alcohol,  published  in  Physiologic  Aspects  of 
the  Liquor  Problem. 

As  far  as  experimental  evidence  goes,  if  alcohol  is  introduced  into 


ALCOHOL  183 

the  body  without  local  irritation,  it  is,  strictly  speaking,  not  a  cir- 
culatory stimulant.  In  moderate  quantities  it  has  no  effect  on  the 
heart  itself,  and  neither  stimulates  nor  depresses  it,  but  this  state- 
ment is  based  on  laboratory  experiments  covering  only  a  short  period 
of  time  and  may  not  hold  good  for  the  effect  in  the  prolonged  daily 
use.  Large  quantities  of  alcohol  weaken  the  heart.  It  has  no  action 
either  on  the  peripheral  or  central  ends  of  the  nerves  which  control 
the  rate  and  force  of  the  heart,  except  under  unusual  circumstances, 
as  in  prolonged  or  severe  intoxication.  In  moderate  quantities  it 
has  no  effect  on  the  arterial  blood-pressure,  but  when  sufficient  has 
been  given  to  induce  a  change  it  is  a  fall  and  not  a  rise,  except  under 
certain  circumstances,  where  the  circulatory  apparatus  is  in  an  ab- 
normal condition.  In  the  early  stages  of  its  action  it  causes  some 
flushing  of  the  skin  and  brain,  and  later,  when  very  large  quantities 
have  been  taken,  dilatation  of  the  abdominal  vessels  occurs.  The  fall 
of  blood-pressure  due  to  very  large  quantities  is  a  toxic  phenomenon, 
a,nd  is  due  to  the  depressant  action  of  the  alcohol  on  the  nervous 
centers  which  control  the  calibers  of  the  arteries  and  also  in  part 
to  the  weakened  heart.  When  alcohol  is  introduced  into  the  circula- 
tion it  acts  as  a  narcotic,  but  owing  to  its  local  effect  on  the  mucous 
membranes,  and  through  its  cerebral  action  on  the  various  parts  of 
the  circulatory  system,  a  train  of  phenomena  may  be  produced  which 
justify,  to  a  certain  degree,  the  term  "circulatory  stimulant."  Most 
common  of  these  is  the  slowing  or  quickening  of  the  pulse-rate,  as 
frequently  observed  in  medical  practice. 

On  the  respiration  alcohol  acts  as  a  respiratory  stimulant  of 
moderate  power  for  human  beings.  During  a  period  of  an  hour  or 
more  after  its  administration  it  causes  an  increase  in  the  volume  of 
air  passing  through  the  lungs  and  in  the  absorption  of  oxygen  (3.5 
per  cent.). 

Highly  flavored  wines,  brandy  and  other  alcoholic  beverages  which 
contain  larger  amounts  of  stimulating  esters,  have  a  more  pronounced 
action  than  ethyl  alcohol,  and  the  stimulating  action  of  alcoholic 
beverages  is  greater  in  the  case  of  fatigued  persons  than  in  those  in 
nowise  exhausted.  Increased  heat  dissipation  always  accompanies 
the  above-named  effects.  The  compensatory  increase  in  heat  produc- 
tion requires  an  increase  in  the  oxidative  processes  in  the  tissues,  and 
the  increased  demands  for  oxygen  is  the  direct  cause  of  the  increased 
activity  of  the  respiratory  center.  Small  doses  of  alcohol  have  also 
the  effect  of  increasing  the  movements  of  the  digestive  tract  and  of 
causing  a  state  of  unrest  or  tension  in  the  skeletal  muscles,  and  thus 
further  adding  to  the  demand  for  oxygen. 

How  far  the  action  of  alcohol  on  the  central  nervous  system,  and 
how  far  its  influence  as  a  protoplasmic  poison  may  modify  its  opera- 
tion as  an  antipyretic ;  how  far  variations  in  the  external  temperature, 
in  the  humidity  of  the  air,  and  in  the  temperature  of  the  body  itself 


184  BEVERAGES  AA'D  STIMULANTS 

influence  its  action,  must  all  receive  further  study.  In  a  word,  the 
detailed  chemic  and  physiologic  studies  similar  to  those  that  have 
been  made  on  other  antipyretics  are  demanded.  Such  studies  will 
probably  tend  to  harmonize  the  conflicting  views  at  present  enter- 
tained in  regard  to  the  use  of  alcohol  in  fever,  and  explain  the  more 
deleterious  effects  of  alcohol  in  polar  and  tropical,  as  compared  with 
temperate  regions. 

The  effect  of  alcohol  on  the  digestion  and  secretion  is  to  increase 
the  flow  of  saliva  from  the  stimulating  effect  of  the  alcoholic  beverage 
in  the  mouth.  This  acceleration  of  secretion  is,  however,  of  brief 
duration.  Not  only  is  the  volume  of  saliva  increased,  but  also  the 
organic  and  inorganic  constituents.  This  effect  is  in  no  sense  peculiar 
to  alcohol,  but  is  common  to  many  so-called  stimulants.  Upon  the 
gastric  secretion  alcohol  and  alcoholic  liquids  have  a  marked  effect, 
increasing  both  the  quantity  of  gastric  juice,  the  amount  of  acid,  and 
the  total  solids,  and  this  action  is  exerted  not  only  by  the  presence  of 
alcoholic  beverages  in  the  stomach,  but  also  indirectly  through  the  in- 
fluence of  alcohol  absorbed  from  the  intestine.  This  increase  in  the 
flow  of  gastric  juice  may  counterbalance  the  greater  or  lesser  retarda- 
tion of  the  digestive  changes  caused  by  alcoholic  beverages.  This 
retardation  may  not  be  great  in  some  instances,  owing  to  the  rapid 
disappearance  of  the  alcohol  from  the  alimentary  canal. 

The  effect  of  alcohol  on  the  nervous  system  varies  greatly  in  differ- 
ent races,  in  different  individuals,  and  under  different  circumstances, 
and  there  are  also  variations  in  its  action  according  to  the  choice  of 
beverage,  though  this  is  by  no  means  constant.  The  environment  is 
another  factor,  and  gay  companions,  bright  light,  and  music  increase 
the  exhilarating  effects.  In  small  quantities  it  produces,  in  most 
individuals,  a  feeling  of  well-being  and  good  fellowship,  and,  in 
larger  quantities,  it  causes  a  tendency  to  loquacity,  gesticulation,  and 
a  feeling  of  self-confidence.  The  face  is  usually  flushed,  the  eyes 
brighter,  and  the  self-control  lessened.  In  still  larger  quantities, 
the  individual  becomes  boisterous,  may  wish  to  sing,  shout,  fight, 
and  in  other  ways  disregard  the  ordinary  conventions  of  life.  Larger 
quantities  are  liable  to  be  followed  by  muscular  incoordination,  shown 
in  the  uncertain  movements,  staggering  gait,  and  stammering  speech. 
Sooner  or  later  sleep  follows,  from  which  the  individual  awakes  with 
various  unpleasant  symptoms,  chief  of  which  are  thirst,  nausea, 
vomiting,  headache,  and  neuralgia,  and  sometimes  acute  or  subacute 
gastritis.  After  very  large  quantities  a  condition  resembling  chloro- 
form anesthesia  supervenes. 

There  are  two  opinions  concerning  the  action  of  alcohol  on  the 
nervous  system,  that  of  Binz  and  others,  who  believe  that  it  fii-st 
stimulates  and  then  depresses,  and  that  of  Schmiedeburg,  Bunge,  and 
others,  who  think  that  it  depresses  from  the  start,  and  explain  the 
apparent  stimulation  by  a  depression  of  the  inhibitory  centers. 


ALVOHOL  185 

On  the  intelleetual  faculties  the  receptive  powers  are  lessened  even 
by  small  quantities,  but  small  quantities  lessen  the  time  required  for 
simple  association  processes,  such  as  rhyming,  while  larger  quantities 
depress  all  the  intellectual  faculties.  The  individual  often  believes 
he  is  doing  better  work  and  more  quickly,  when,  in  reality,  the  work 
is  not  as  good,  and  takes  a  longer  time  than  without  the  alcohol.  Ex- 
periments with  typesetters  and  others  show  that  alcohol  causes  the 
worker  to  make  a  greater  number  of  errors  than  he  would  without  it. 

The  deleterious  effects  of  larger  quantities  of  alcoliol  than  the 
individual  can  metabolize,  continued  over  long  periods  of  time,  are 
too  familiar  to  need  description.  While  it  is  true  that  many  in- 
dividuals take  considerable  alcohol  daily  over  long  periods  of  time 
without  causing  any  pathologic  changes,  we  have  demonstrated  on 
animals  and  it  is  frequently  seen  in  man  that  cirrhosis  of  the  liver, 
kidney,  and  other  organs  may  be  caused  by  alcohol,  although  fatty 
degeneration  of  the  liver,  kidneys,  heart,  and  vessels  is  rather  the 
more  common  change.  The  more  concentrated  the  alcohol  and  the 
larger  the  quantity  taken  in  a  single  dose,  the  more  liable  is  alcohol 
to  cause  tissue  changes.  There  is  considerable  reason  to  believe  that 
alcohol  is  not  as  great  a  factor  in  causing  arteriosclerosis  as  was 
formerly  believed. 

The  Use  of  Alcohol  as  a  Food  and  in  Medicine.^ — The  use  of 
alcohol  is  of  undoubted  value  in  medicine,  and  the  sweeping  con- 
demnation that  it  has  received  from  many  quarters  in  recent  years  is 
not  merited.     The  use  and  abuse  have  been  confused. 

As  a  food  it  can  be  utilized  only  within  certain  limits,  as  only  what 
would  represent  2  ounces  of  alcohol  can  be  metabolized  by  the  average 
individual  within  twenty -four  hours.  For  some  this  is  too  low  an 
estimate,  and  for  others  even  this  amount  could  not  be  utilized  with- 
out the  production  of  symptoms  or  unpleasant  after-effects.  In  fevers 
and  other  conditions,  where  sufficient  food  cannot  be  administered, 
alcohol  may  be  added  to  the  diet  with  good  effect,  and  in  toxic  condi- 
tions, such  as  are  often  seen  in  typhoid,  it  is  of  incalculable  value. 
It  is  readily  absorbed,  easily  assimilated,  and  seems  in  these  toxic 
cases  to  aid  in  combating  the  toxemia! 

It  is  frequently  used  as  a  stomachic,  to  produce  an  appetite  and 
to  stimulate  the  secretion  of  gastric  juice.  It  acts  also  as  a  respiratory 
stimulant,  and  may  be  used  in  conditions  of  heart  weakness  and  dis- 
turbances of  the  circulation,  as  through  its  cerebral  and  local  action 
it  may  influence  the  circulation  favorably,  causing,  as  it  were,  the  re- 
establishment  of  more  or  less  normal  conditions  by  dilating  superficial 
vessels,  and  by  slowing  or  accelerating  the  pulse-rate,  and  by  its 
numerous  indirect  influences  causing  a  different  balance  in  the  parts 
and  functions  of  the  vasculatory  apparatus. 

It  is  contraindicated  in  individuals  who  have  previously  been 
victims  of  the  alcohol  habit  and  are  liable  to  acquire  it  again,  and  in 
individuals  who  come  from  families  that  are  prone  to   form  drug 


186  BEVERAGES  AND  STIMULANTS 

habits.  It  should  not  be  used  where  it  causes  unpleasant  symptoms  or 
excitement,  although  these  may  be  due  to  too  large  doses.  If  the 
odor  is  apparent  on  the  breath  some  time  after  the  administration, 
it  is  very  probable  that  the  quantity  administered  has  been  too  great. 
Small,  repeated  doses,  well  diluted  with  water,  give  better  results 
than  larger  or  more  concentrated  doses.  The  best  indications  that 
the  alcohol  is  well  borne  is  a  change  for  the  better  in  the  general 
appearance  and  condition,  with  improved  circulation  as  evidenced 
in  the  appearance,  pulse-rate,  arterial  tension,  and  the  quality  of  the 
heart  sounds.  In  severe  toxic  conditions,  from  14  to  1  ounce  of 
whisky  and,  in  some  instances,  more  may  be  given  every  one,  two,  or 
three  hours,  according  to  the  effect  produced. 

Consumption  of  Alcohol.^ — According  to  Thompson,  the  total  con- 
sumption of  alcoholic  beverages  a  year  in  America  is  more  than 
1,000,000,000  gallons.  The  following  table,  taken  from  Thompson's 
Dietetics,  p.  239,  gives  the  annual  per  capita  consumption  of  alcoholic 
beverages  in  1890 : 

Beer.  Wine.  Spirits. 

England    30.31  0.39  1.02 

France    5.10  21.80  1.84 

Germany 25.50  1.34  1.84 

United  States    12.30  0.44  0.84 

Alcoholic  beverages  are  divided  into  several  classes,  e.  g.,  spirits, 
liqueurs  and  bitters,  malt  liquors,  wines,  etc, 

SPIRITS 

Spirits  are  proceed  by  fermenting  saccharine  substances  and  ob- 
taining the  alcohol  by  distillation.  Of  these  substances,  corn,  rice, 
barley,  molasses,  and  potatoes  are  those  most  commonly  utilized  for 
this  purpose.  In  addition  to  the  alcohol,  by-products  are  formed, 
and  it  is  to  these  that  spirits  owe  their  characteristic  flavor  and  odor. 
The  by-products  contain  the  higher  alcohols,  such  as  propyl,  butyl, 
and  amyl  alcohol,  this  mixture  forming  what  is  known  as  fusel  oil. 

Whisky. — The  United  States  Pharmacopeia  formerly  defined  whiskj^ 
as  ''an  alcoholic  liquid  obtained  by  distillation  of  the  mash  of  fer- 
mented grain  (usually  of  mixtures  of  corn,  wheat,  and  rye)  and  at 
least  four  years  old. ' '  Whisky  possesses  an  alcoholic  strength  of  from 
50  to  58  per  cent,  by  volume.  It  should  be  free  from  disagreeable 
odor.  The  ether  and  aldehyds  contained  in  whisky  become  altered  in 
character  as  it  ages,  and  the  flavor  is  thus  rendered  more  agreeable. 

Brandy. — In  the  United  States  Pharmacopeia  brandy  was  defined 
as  an  "alcoholic  liquid  obtained  by  the  distillation  of  the  fermented 
unmodified  juice  of  fresh  grapes,  and  at  least  four  years  old." 
Brandy  contains  from  46  to  55  per  cent,  by  volume  of  alcohol.  The 
quality  of  brandy  depends  upon  the  variety  of  grapes  used  and  upon 
the  length  of  time  the  brandy  is  allowed  to  stand:  the  older  the 
brandy,  the  better  the  quality.     With  brandy,  just  as  with  whisky, 


ALCOHOL 


187 


on  standing  ethers  and  aldehyds  are  produced  to  which  the  special 
flavor  of  the  brandy  is  due. 

The  color  of  brandy  is  due  to  the  tannic  acid  extracted  from  the 
oak  casks  in  which  the  brandy  is  contained.  There  are  many  inferior 
grades  of  brandy  on  the  market,  some  being  merely  alcohol  colored 
and  flavored  with  various  essences. 

Rum. — Rum  is  the  product  of  the  distillation  of  fermented  molasses, 
its  flavor  being  due  to  certain  by-products.  Some  of  the  so-called 
"rum"  of  the  market  is  made  by  adding  various  essences  to  alcohol. 
On  standing,  by  the  development  of  special  aldehyds  and  ethers,  rum 
improves  in  quality.  It  contains  about  the  same  percentage  of  alcohol 
as  do  brandy  and  whisky. 

Gin. — Gin  is  produced  by  the  distillation  of  rye  and  malt  mash, 
its  flavor  being  due  to  juniper  berries  which  are  added  during  fer- 
mentation. Inferior  grades  of  gin  are  manufactured  by  adding  juni- 
per berries,  turpentine,  etc.,  to  alcohol.  Gin  contains  from  15  to  20 
per  cent,  of  alcohol ;  but  the  strength  is  sometimes  increased  by  the 
addition  of  alcohol,  so  that  it  may  contain  as  much  as  35  per  cent,  of 
alcohol. 

LiaUEUES  AND  BITTERS 

Liqueurs  or  cordials  and  bitters  contain  a  large  proportion  of 
alcohol,  and  a  high  percentage  of  sugar  and  essential  oils.  The  fol- 
lowing table  gives  the  composition  of  some  of  the  more  common 
liqueurs  and  bitters : 

Analysis  of  Liqueurs. — [Rupp.) 


Alcohol. 

Extracts. 

Sugar. 

Liqueur. 
(100  c.c.) 

Volume. 

Weight. 

Salt. 

Absinthe 

Anise 

Per  cent. 
55.0 
40.0 
32.5 
35.0 
48.0 
52.5 
53.0 
44.0 

Per  cent. 
44.0 
32.0 
26.0 
28.0 
38.4 
42.0 
42.4 
35.2 

Grams. 

1.8 
33.2 
29.8 
44.0 
12.0 
27.9 
35.0 
35.4 

Grams. 
1.1 
30.9 
28.2 
43.2 
7.5 
26.5 
33.4 
34.0 

Grams. 
0.220 
0.310 

Kiimmel 

Peppermint 

Angostura 

Cura9oa 

Benedictine 

Chartreuse 

0.100 
0.090 
0.140 
0.075 
0.110 
0.091 

MALT  LIQUORS 

Under  the  heading  of  malt  liquors  are  included  beer  or  ale  and 
stout  or  porter.  These  beverages  are  made  by  fermenting  malt  and 
hops.  Malt  is  produced  by  allowing  moistened  barley  to  germinate 
at  a  moderate  temperature ;  in  this  process  the  diastatic  ferment  acts 
upon  the  starch,  converting  it  into  sugar  and  dextrin.  After  drying 
and  grinding,  the  malt  is  mixed  with  water  and  thus  made  into  a 


188 


BEVERAGES  AND  STIMULANTS 


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mash,  which   is  again   heated,   thus  more   completely   ehauging   the 
starches  into  sugaK 


ALCOHOL 


189 


Beer. — The  quality  of  the  beer  depeuds  largely  upon  the  tempera- 
ture at  which  the  process  of  manufacture  is  carried  on.  Pale  beer 
is  produced  by  drying  the  mash  at  low  temperature,  whereas  the 
darker  beers  are  the  result  of  drying  the  malt  at  a  higher  temperature. 
The  infusion  of  malt  is  termed  "nmsh."  The  diastatic  action  of 
malt  is  inhibited  by  boiling  the  "mash"  with  hops;  in  this  way 
tannic  acid  and  extractives  are  withdrawn.  The  mash  is  now  cooled 
and  fermented  with  yeast.  In  order  to  secure  a  pure  beer,  great 
caution  must  be  exercised  to  procure  pure  yeast.  The  yeast  that 
rises  to  the  surface  after  fermentation  is  skimmed  off,  the  remainder 
settling  at  the  bottom.  Beer  is  now  placed  in  casks,  the  yeast  which 
was  allowed  to  remain  continuing  to  produce  fermentation.  The 
longer  this  process  is  allowed  to  continue,  the  stronger  is  the  per- 
centage of  alcohol  in  beer.  The  mild  or  bitter  beers  are  distinguished 
by  the  relative  proportion  of  hops  contained  in  them;  the  milder 
forms  contain  considerable  quantities  of  hops,  whereas  the  bitter 
ones  contain  but  small  amounts. 

Volatile  bodies  are  also  produced  which,  in  addition  to  the  carbonic 
acid  gas  formed,  add  to  the  pleasant  flavor  of  the,  beer.  In  order  to 
add  to  the  keeping  qualities  of  beer  various  preservatives  are  added, 
such  as  calcium  sulphate,  salicylic  acid,  etc.  These  substances  not 
onl}'  att'ect  the  flavor  of  the  beer,  but  when  taken  in  large  quantities 
have  a  deleterious  effect  on  the  system. 

Porter  and  Stout. — Porter  and  stout  are  made  by  fermenting 
malt,  the  latter,  however,  being  roasted,  during  which  process  a  cer- 
tain amount  of  caramel  is  produced.  It  is  to  this  substance  that  the 
dark  color  is  due.  Beer  as  well  as  stout  contains  from  3  to  8  per 
cent,  of  alcohol,  from  2  to  5  per  cent,  of  dextrin,  and  from  0.5  to  1 
per  cent,  of  sugar. 

The  following  table  ^  gives  the  composition  of  some  malt  liquors : 


1 

u 

1 

o 

"2 

2 
ft. 

•6 

00  "0 

cs  oi 

>.« 

< 

.a 

Bavarian  winter  beer 
Bavarian  summer  beer 
Munich  Hofbrau    .    . 
Munich  Spatenbi-au  . 

Pilsener 

Munich  Bock-beer     . 
English  ale  and  porter 
Berlin  white  beer  .    . 

91.81 
90.71 

91.15 

88.72 
89.10 

3.21 

3.68 
3.70 
3.23 
3.46 
4.07 
4.89 
3.91 

4.99 
5.61 
5.87 
6.61 
4.97 
7.23 
6.03 
4.85 

0.81 
0.49 

0.37 
0.71 
0.53 

0.44 

0.87 

6.90 
0.84 

2.92 
4.39 

0.116 

0.128 

0.160 
0.170 
0.310 

0.20 

0.22 

0.20 
0.27 
0.31 

The  table  on  page  188,  taken  from  Crumpton,  Fermented  Alcoholic 
Beverages,  U.  S.  Department  of  Agriculture,  Bulletin  No.  13,  1887, 
gives  an  analysis  of  American  malt  liquors. 


1  Leyden's  Handbuch  der  Ernahrungs-Therapie,  p.  105. 


190 


BEVERAGES  AND  STIMULANTS 


WINE 

Wine  is  produced  by  the  fermentation  of  grape-juice,  the  juice 
being  first  pressed  from  the  grape  by  crushing.  There  are  a  number 
of  factors,  such  as  the  character  of  the  grape  utilized,  its  cultivation, 
and  the  method  of  manufacturing,  that  enter  into  the  production  of  a 
good  wine. 

The  following  table,  taken  from  Dupre,^  gives  the  main  constituents 
of  grape-juice  and  the  wine  that  is  manufactured  therefrom.  Grape- 
juice  or  must  contains — 


10  to  30  per  cent. 


lo  to  6  per  cent. 


5   to  22  per  cent. 


-0.3  to  0.8  per  cent. 


Vegetable  mucus. 

Essential  oils. 

Extractives. 

Mineral  substances. 

Tannic  acid. 

Coloring-matters  "t  From  the  skins  and 

Fatty  substances  /  kernels. 

Ethers  of  foregoing  alcohols  and  acids. 

Glycerin. 

Aldehyd. 

Carbonic  acid  and  ammonia. 

Trimethylamin. 

Oils  produced  by  fermentation. 

Albuminous  matter. 

Vegetable  mucus. 

Coloring-matter. 

Tannic  acid. 

Extractives. 

Mineral  matters,  0.15  to  0.6  per  cent. 


Water 

Grape-sugar 

Fruit-sugar 

Malic  acid. 

Tartaric  acid. 

Racemic  acid. 

Albuminous  substances 

Wine  contains — 
Water 
Grape-sugar 
Fruit-sugar 
Ethylic  alcohol 
Propylic  alcohol 
Butylic  alcohol 
Amylic  alcohol 
Other  higher  alcohols, 
Malic  acid 
Tartaric  acid 
Racemic  acid 
Succinic  acid 
Acetic  acid 
Formic  acid 
Propionic  acid 
Butyric  acid 

Among  the  constituents  of  the  juice  of  the  grape  are  albuminous 
substances,  grape-  and  fruit-sugar,  and  tartaric  and  tannic  acids. 
The  yeast  that  grows  upon  the  albumins  ferments  the  sugar,  with  the 
production  of  alcohol.  The  character  of  the  wine  depends  upon  the 
quantity  of  albuminous  material  present :  if  there  is  little  albumin, 
the  yeast  soon  ceases  in  its  work  of  converting  sugar  into  alcohol,  in 
consequence  of  which  the  wine  produced  is  sweet;  on  the  other  hand, 
if  there  is  much  albuminous  material  present,  the  yeast  continues  to 
grow  until  all  the  sugar  is  converted  into  alcohol. 

Ordinarily,  wine  does  not  contain  more  than  16  per  cent,  of  alcohol, 
inasmuch  as  the  action  of  the  yeast  is  inhibited  by  this  percentage  of 
alcohol.  Frequently,  however,  wine  is  "fortified"  by  the  addition  of 
alcohol ;  this  is  true  of  port,  which  is  always  ' '  fortified. ' ' 

The  yeast  used  in  the  fermentation  of  grape-juice  is  obtained  in 
pure  cultures  and  added  to  the  juice  to  produce  the  required  flavor. 

The  methods  of  wine-production  vary  greatly,  and  require  no 
description  here.  Suffice  it  to  say  that  the  fermentation  at  first  lasts 
from  three  to  six  weeks ;  the  albuminous  material  is  removed  a  number 

1  "What  is  Wine  ?"     Popular  Science  Review,  vol.  vii. 


ALCOHOL  191 

of  times,  and  the  wiue  is  then  placed  in  casks ;  here  the  percentage  of 
alcohol  increases,  and  the  color  of  the  wine  becomes  fixed.  Fermenta- 
tion still  goes  on,  however,  and  may  continue  for  many  years,  thus 
increasing  the  percentage  of  alcohol. 

Ethers  are  also  produced,  w^hich  continue  to  be  formed  even  after 
the  wine  has  been  placed  in  bottles.  The  color  of  red  wine  is  due  to 
a  coloring-matter  contained  in  the  skin  of  the  grapes. 

Acids. — The  most  important  acids  contained  in  wine  are  tartaric, 
malic,  and  tannic;  others  of  less  importance  are  acetic  and  succinic. 
Tartaric  acid  occurs  in  combination  with  potassium  as  potassium 
bitartrate.  The  total  amount  of  acids  in  wine  varies,  but  rarely 
exceeds  0.5  per  cent. 

Alcohol. — There  are  several  alcohols  present  in  wine;  ethyl  alcohol 
occurs  in  largest  quantity;  amyl,  propyl,  and  butyl  alcohol  are  also 
present  in  varying  amounts.  As  has  been  stated,  natural  wine  never 
contains  more  than  16  per  cent,  of  alcohol;  if  it  contains  more  than 
this  amount,  it  has  been  "fortified."  This  is  often  done,  especially 
when  the  wine  is  to  be  shipped  from  warm  countries  to  foreign  dis- 
tricts, to  prevent  it  souring. 

Sugar. — Sour  wines  contain  about  1  per  cent.,  and  sweet  wines 
about  4  per  cent.,  of  sugar;  it  is  evident,  therefore,  that  sugar  is 
present  in  too  small  a  quantity  to  be  of  any  food-value. 

Ethers. — Man}^  varieties  of  ethers  are  present  in  wine ;  they  are 
produced  by  the  action  of  the  alcohols  and  acids  upon  each  other.  It 
is  to  the  character  and  quantity  of  the  ethers  contained  in  them  that 
the  flavor  of  various  kinds  of  wines  is  largely  due. 

Glycerin. — Glycerin  is  present  in  wine  in  about  one-fourteenth  of 
the  volume  of  the  alcohol. 

Extractives. — A  large  part  of  the  solid  material  of  the  wine  is  made 
up  of  extractives,  mainly  the  carbohydrates,  as  pectins  and  gums. 

Varieties  of  Wines. — From  a  dietetic  standpoint  the  classification 
of  Chambers  is  probably  the  most  practical ;  according  to  this  author, 
wines  are  divided  into  seven  classes: 

1.  Strong  dry  wines.  4.  Acid  wines. 

2.  Strong  sweet  wines.  5.  Sparkling  wines. 

3.  Aromatic  wines.  6.  Perfect  wines. 

7.  Kough  or  astringent  wines. 

1.  Strong  Dry  Wines. — These  are  wines  that  contain  a  large  per- 
centage of  alcohol,  to  which,  as  a  rule,  additional  alcohol  has  been 
added  in  their  production ;  in  other  words,  they  are  ' '  fortified. ' '  Ex- 
amples of  this  class  of  wines  are  port,  sherry,  and  Madeira.  In  cases 
of  fever  these  wines  are  utilized  in  place  of  whisky.  Port  contains 
from  15  to  20  per  cent,  of  alcohol  and  considerable  tannic  acid. 
Sherry  is  a  fortified  wine;  it  contains  from  15  to  22  per  cent,  of 
alcohol. 


192 


BEVERAGES  A\D  STIMULANTS 


2.  Strong  Sweet  Wines. — These  wines  contain  fruit-sugar  in  quanti- 
ties sufficient  to  act  as  a  preservative  and  prevent  furtJier  fermenta- 
tion. Under  this  head  may  be  mentioned  Tokay,  Malaga,  and  SM^eet 
champagne.  They  contain  from  18  to  22  per  cent,  of  alcohol  and  from 
3  to  5  per  cent,  of  sugar. 

3.  Aromatic  Wines. — Aromatic  wines  possess  a  superior  flavor  and 
contain  essential  oils  and  considerable  alcohol ;  examples  of  this  class 
of  wines  are  Moselle,  Capri,  and  some  of  the  Rhine  wines. 

4.  Acid  Wines. — The  distinguishing  feature  of  this  class  of  wines 
is  the  large  quantity  of  acid  they  contain. 

5.  Sparkling  Wines. — Sparkling  wines  contain  considerable  quanti- 
ties of  carbonic  acid  gas,  to  which  their  exhilarating  effect  is  due. 
The  chief  variety  of  this  class  of  wines  is  champagne.  The  dryness 
or  sweetness  of  champagne  depends  upon  the  proportion  of  cane- 
sugar  and  cognac  added  during  the  process  of  manufacture.  In  the 
manufacture  of  dry  champagne  8  per  cent,  of  sugar  is  added,  while 
the  sweet  brands  contain  as  much  as  16  per  cent.  Since  dry  cham- 
pagne idoes  not  contain  large  quantities  of  sugar,  and  since  the  larger 
part  of  the  sugar  it  originally  contained  has  disappeared  during  fer- 
mentation, it  is  considered  less  likely  to  produce  flatulence,  and  is 
therefore  preferred  by  invalids.  Dry  champagne  is  a  pure  wine 
containing  from  9  to  12  per  cent,  of  alcohol  and  from  1  to  4  per  cent, 
of  sugar. 

6.  Perfect  Wines. — Perfect  wines  are  defined  by  Chambers  as  those 
containing  alcohol,  water,  sugar,  ethereal  flavors,  fruity  extractives, 
and  acids.  Under  this  head  come  Burgundy  and  Bordeaux.  Bur- 
gundy contains  a  rather  large  percentage  of  alcohol  and  extractive 
matter;  it  is,  therefore,  said  to  have  considerable  "body."  Good 
Bordeaux  wines  are  thoroughly  fermented,  and,  together  with  the 
Burgundies,  contain  very  little  sugar;  they  are,  therefore,  well  borne 
by  invalids,  and  are  especially  useful  as  tonics  during  convalescence 
from  protracted  illnesses. 

Rough  Wines. — Rough  wines  contain  considerable  quantities  of 
tannic  acid,  to  which  they  owe  their  astringent  effect.  They  contain 
little  alcohol,  and  are  of  slight  value  for  medicinal  purposes. 

Dupre  gives  the  following  table  : 


Wine. 


fl  s  S 


Hock  fthree  samples 

Claret  (three  samples) 

Hungarian  wine  (three  samples) 
Greek  wine  (three  samples  I   .   .   . 

Sherry  (three  samples) 

Madeira  (two  samples) 

Port  (three  samples) 

Marsala 


9  73  0  399 
9.68  0.390 
lO.lfi  I  0.4.=>4 


12.35 
17.80 
17.82 
18.11 
16.80 


0.342 
0.286 
0.373 
0.309 
0.206 


r    ^^  c; 
fe  O  (S 


0.088 
0.167 
0.192 
0.215 
0.161 
0.247 
0.090 
0.120 


a3>o 
H  as 


0.506  0.062 
0.599  0.243 
0.694  0.077 
0.611  i  0.225 
0.487  !  3.015 
0.680  !  1.850 
0.434  !  2..540 
0.361    3.500 


1.920 
2.124 
1.906 
2.507 
5.060 
4.440 
5.340 
5.360 


0.17 
0.21 
0.18 
0.30 
0.50 
0-37 
0.23 
0.26 


0.042 
0.0.38 
0  046 
0.048 
0.061 
0.096 
0.053 
0.049 


ALCOHOL 


193 


The  following  tables  ^  give  tlie  average  composition  of  some  Anreri- 
cau  wines : 


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S 

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0.016 
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6.009 

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0 
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0  0 

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t~  o> 

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0 

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m  2                       pjaoXio 

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a  1 

8.25 
9.10 

10..59 

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ai 

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to 

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t-  lo  r^  'J' 

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01 

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c 

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0 

a« 

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Malbeck    . 
Cabernet-Sa 
iSt.  MaCaire 
Claret.  .   . 

be 

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IS 

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s 

a 

1  Compiled  from  The  Composition  of  American  Wines,  VV.  D.  Bigelow,  U.  S. 
Department  of  Agriculture,  Bulletin  No.  59,  1900. 
13 


194 


BEVERAGES  AND  STIMULANTS 


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nmissB^oj 


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196  BEVERAGES  AND  STIMULANTS 

ACTION  AND  THERAPEUTIC  USE  OF  MALT  LIQUORS  AND  WINES 

Malt  liquors,  when  taken  in  moderate  quantities,  seem  to  aid  diges- 
tion, increase  the  appetite,  and  stimulate  gastric  secretion.  Occasion- 
ally, especially  in  those  who  lead  a  sedentary  life,  they  give  rise  to 
indigestion  and  gastric  acidity.  On  account  of  the  large  quantities 
of  carbohydrates  they  contain  they  have  considerable  food-value.  The 
use  of  malt  liquors  is  contraindicated  especially  in  such  conditions  as 
gout,  obesity,  diabetes,  and  diseases  of  the  urinary  tract. 

Wines  appear  to  exert  a  depressing  effect  on  the  gastric  secretion. 
Taken  in  moderate  quantities,  however,  by  increasing  the  appetite 
and  the  motor  function  of  the  stomach,  this  depressing  effect  is  not 
only  overcome,  but  the  digestion  is  also  greatly  improved. 

Anstie  ^  gives  the  following  conclusions  as  to  the  use  of  wine  in 
health : 

"Wines  for  daily  use  by  healthy  adults  should  not  on  the  average 
contain  more  than  10  per  cent,  absolute  alcohol  (by  weight)  ;  8  or  9 
per  cent,  is  better. 

' '  If  wine  be  used  as  the  daily  drink,  it  is  best,  as  far  as  may  be,  to 
use  only  one  kind  at  a  time  and  no  other  form  of  alcoholic  liquor. 

"Sound  natural  wines  are  to  be  obtained  at  the  best  economic  ad- 
vantage from  the  Bordeaux  district ;  the  red  wines  are  to  be  preferred. 
Rhine  wines  (white)  are  equally  excellent,  but  more  expensive. 

"Hungarian  wines  are  also  in  many  instances  excellent,  but  they 
are  unequal  in  quality,  owing  to  defects  of  manufacture. 

"Greek  wines  labor  under  the  same  defects. 

"The  fortified  wines,  as  a  class,  develop  no  proper  vinous  qualities 
till  they  have  been  for  some  years  in  bottle.  Sherry,  however,  is 
greatly  superior  to  the  other  wines  of  this  class  in  the  rapidity  with 
which  it  develops  the  volatile  ethers. 

"Fortified  wines  in  small  quantities,  especially  sherry,  for  the 
reason  just  named,  are  the  appropriate  stimuli  of  certain  kinds  of 
infantile  and  youthful  debility,  and  of  the  enfeebled  nervous  system 
of  old  persons. 

' '  Half  a  bottle  of  a  natural  wine  a  day  for  a  sedentary  and  a  bottle 
a  day  for  a  vigorous  and  actively  employed  adult  affords  a  reasonable 
and  prudent  allowance  of  alcohol,  and  this  quantity  of  wine,  either 
alone  or  with  water,  will  be  enough  to  satisfy  the  needs  of  moderate 
persons  for  a  beverage  at  luncheon  and  dinner,  the  only  two  meals 
at  which  alcohol  should,  as  a  rule,  be  taken." 

CIDER 

Cider  is  a  beverage  prepared  from  the  fermented  juice  of  ripe 
apples.  The  amount  of  alcohol  contained  in  this  beverage  varies 
between  3  and  8  per  cent,  by  volume.     It  also  contains  malic  acid, 

1  On  the  Uses  of  Wines  in  Health  and  Disease,  1877,  p,  39. 


ALCOHOL  197 

salts,  sugar,  albuminoids,  and  extractives.     Cider  is  a  diuretic  drink 
and  acts  as  a  laxative.     On  exposure  it  undergoes  an  acetic  acid 
fermentation,  whereby  it  is  rendered  unfit  for  drinking  purposes. 
The  table  on  page  195  ^  gives  analyses  of  American  ciders. 

1  Crampton,  Foods  and  Food  Adulterants,  U.  S.  Department  of  Agriculture, 
Bulletin  No.  13,  1877. 


VARIOUS  FACTORS  IN  RELATION  TO  DIET 
CONCENTRATION  OF  FOOD 

Concentrated  foods  are  those  from  which  the  larger  portion  of 
the  water  present  has  been  abstracted,  and  thus  the  weight  and  the 
bulk  of  the  food  diminished.  There  are  many  patented  concentrated 
foods  on  the  market.  They  find  their  chief  use  in  the  treatment  of 
patients  who  take  too  little  of  the  usual  forms  of  food  to  maintain 
strength,  and,  second,  in  cases  where  it  is  important  that  a  large 
quantity  of  nourishment  be  taken. 

Food  can  be  concentrated  to  various  degrees.  Desiccated  meat  is 
the  most  concentrated  form  of  protein:  sugar,  the  most  concentrated 
form  of  carbohydrate ;  and  olive  oil,  the  most  concentrated  form  of 
fat. 

1.  Concentrated  Proteins. — These  foods  are  prepared  from  milk, 
meat,  eggs,  and  vegetables.  Meat  is  concentrated  by  drying,  and  in 
this  form  it  is  generally  indigestible ;  which  can,  however,  be  overcome 
by  predigestiou  or  powdering;  in  this  class  of  foods  are  included 
somatose,  pemmican,  and  Mosquera's  ''Beef  Meal."  Among  the  con- 
centrated foods  derived  from  the  casein  of  milk  are  nutrose,  eucasein, 
etc.  Eggs  are  dried  i)i  vacuo;  sugar  is  usually  added,  and  the  eggs 
are  then  pulverized.  Of  the  vegetable  proteins  utilized  in  concen- 
trated form  are  aleuronat  and  legumin. 

2.  Concentrated  Carbohydrates. — Sugar  is  the  most  important  of 
the  concentrated  carbohj'drates.  In  this  form,  however,  it  is  apt  to 
disagree  and  cause  fermentation.  To  this  class  of  concentrated  car- 
bohydrates belong  the  malt  extracts, 

3.  Concentrated  Vegetables. — Many  vegetables,  such  as  potatoes, 
carrots,  cabbage,  and  the  like,  are  concentrated  by  drying.  They  are 
utilized  only  in  those  instances  in  which  it  is  impossible  to  secure 
fresh  vegetables. 

Bread  is  frequently  dried  and  eaten  in  the  form  of  "hard-tack," 
when  it  is  impossible,  as  during  voj^ages,  to  obtain  fresh  bread. 

PRESERVATION  OF  FOOD 

By  preservation  of  food  is  meant  the  process  by  which  the  food  is 
so  changed  that  it  can  be  kept  for  a  longer  or  shorter  period  of  time 
without  undergoing  putrefaction.  The  process  of  fermentation  is 
induced  by  micro-organisms  present  in  the  atmosphere  coming  into 

198 


PRESERVATION  OF  FOOD  199 

contact  with  the  food  and  contaminating  it.  Since  putrefactive 
germs  require  a  certain  amount  of  moisture  and  heat  for  their  growth, 
such  foods  as  contain  little  water  and  that  are  not  kept  too  warm 
are  not  so  likely  to  undergo  decomposition ;  on  the  other  hand,  foods 
containing  much  water  undergo  fermentation  very  rapidly.  To  pre- 
vent this  process  four  methods  of  preservation  are,  according  to  Yeo,^ 
available : 

1.  Drying.  2.  Exclusion  of  the  air.  3.  Exposure  to  cold.  4. 
Treatment  with  antiseptic  chemic  agents. 

1.  Drying. — By  this  process  a  large  proportion  of  the  water  is 
abstracted.  Pemmican  is  a  form  of  meat  preserved  by  this  method. 
Vegetables,  such  as  carrots,  peas,  potatoes,  etc.,  are  also  preserved 
by  drying.  Milk,  in  the  form  of  nutrose,  eggs,  as  egg  powder,  and 
fruits  are  often  preserved  in  this  manner. 

2.  Exclusion  of  Air. — Air  may  be  prevented  from  coming  into 
contact  with  food  in  a  number  of  ways :  by  immersing  the  food  in  oil 
or  fat;  by  heating  the  food,  so  as  to  evaporate  the  external  layers; 
by  coating  with  some  impermeable  substance,  as  oil,  salt,  sawdust, 
varnish,  or  paraffin.  Fish  are  frequently  preserved  by  immersion  in 
oil  or  by  smoking.  Ham  and  bacon  are  preserved  by  smoking,  by 
which  process  the  outer  surface  becomes  coagulated  and  impermeable. 
Eggs  are  preserved  by  covering  the  fresh  eggs  with  some  impermeable 
substance,  such  as  oil,  fat,  beeswax,  or  sawdust.  In  order  properly 
to  preserve  food  by  exclusion  of  air  it  is  highly  important  that  the 
food  be  perfectly  fresh,  and  that  any  air  that  may  be  present  be 
expelled. 

In  canning,  the  food  to  be  preserved  is  heated  in  tin  cans  until 
steamed,  when,  all  the  air  having  been  expelled,  the  can  is  soldered  and 
rendered  air-tight.  Various  methods  have  been  resorted  to,  to  obviate 
the  necessity  of  cooking  in  preserving  food.  McCall  advises  the 
partial  exclusion  of  air  and  the  disinfection  of  what  remains  with 
sodium  sulphite.  A  method  of  replacing  the  air  by  nitrogen  and 
sulphurous  acid  has  also  been  recommended. 

3.  Exposure  to  Cold. — Food  can  be  preserved  indefinitely  by  ice. 
Meat  and  fish,  which  are  often  preserved  by  this  means,  should  be 
cooked  at  once  after  thawing.  Frozen  meat  loses  about  10  per  cent, 
more  of  its  nutritive  value  in  cooking  than  fresh  meat.  Frequently 
food  is  not  kept  directly  on  ice,  but  in  refrigerating  chambers ;  it  can 
thus  be  shipped  many  thousands  of  miles  on  land  or  water  without 
showing  the  slightest  tendency  to  decomposition.  The  use  of  cold 
storage  for  indefinite  periods  of  time  is  to  be  condemned,  and  storage 
warehouses  should  be  compelled  to  brand  all  stored  food  as  such, 
as  well  as  with  the  date  of  entrance. 

4.  Treatment  with  Antiseptic  Chemic  Agents. — Under  ordinary 

1  Food  in  Health  and  Disease,  p.  176. 


200  VARIOUS  FACTORS  /iV  RELATION  TO  DIET 

circumstances  the  only  chemic  agents  allowable  in  preserving  food 
are  salt,  sugar,  vinegar,  wood  smoke,  and  spices. 

Salting. — The  salting  of  food  is  a  method  that  has  been  practised 
for  many  centuries.  In  this  way  meat  and  fish  are  easily  preserved. 
The  pale  color  of  the  meat  produced  by  salting  is  overcome  by  adding 
a  little  saltpeter  in  addition  to  common  salt.  By  salting,  considerable 
proteins  are  extracted  from  the  meat — according  to  Liebig,  one-third 
of  the  nutritive  value  of  the  meat  is  lost  in  this  way.  After  the  salt- 
ing has  been  accomplished  it  is  often  followed  by  smoking. 

Sugar  in  strong  solution  acts  as  an  antiseptic,  and  fruits  are  thus 
often  preserved  in  concentrated  syrups. 

Vinegar  acts  as  an  antiseptic  in  preserving  cucumbers,  pickles, 
oysters,  etc. 

Spices. — Recent  observations  have  shown  that  certain  spices  exert 
a  very  marked  preservative  action.  Cinnamon,  cloves,  and  mustard 
are  the  most  powerful,  nutmeg  and  allspice  somewhat  less  active,  while 
ginger,  black  and  cayenne  pepper  are  ineffective. 

Other  Antiseptics  for  Preserving  Foods. — Among  these  sub- 
stances are  sulphur  vapor ;  weak  carbolic  acid ;  strong  acetic  acid ; 
injections  of  alum  and  aluminium  chlorid  into  the  blood-vessels ;  boric 
acid;  borax;  salicylic  acid;  formaldehyd. 

Chittenden  and  Gies  ^  have  studied  the  effect  of  borax  and  of  boric 
acid  on  the  general  nutrition.  They  conclude  that,  taken  in  small 
doses  for  a  long  time,  borax  does  not  alter  metabolism  or  disturb 
nutrition.  In  larger  doses  borax  retards  protein  and  fat  assimilation. 
In  very  large  doses  it  causes  nausea,  vomiting,  and  diarrhea.  (See 
Food  Adulteration.)  Wiley  ^  has  made  an  extended  study  of  food 
preservatives,  and  concludes  that  boric  acid  and  borax  used  even 
in  small  quantities  over  long  periods  of  time  disturb  appetite, 
digestion  and  the  general  health.  The  fact  that  certain  individuals 
may  take  small  amounts  of  certain  food  preservatives  for  long  periods 
of  time  without  injury  is  no  argument  in  favor  of  their  use,  as  we 
have  no  method  of  determining  who  will  be  and  who  will  not  be 
injured  in  this  way.  Wiley  states  positively  that  there  is  no  necessity 
for  using  either  chemic  preservatives  or  artificial  coloring-matter  in 
food-products.  Food  laws  should  be  enacted  and  carried  out  pro- 
hibiting the  use  of  coloring-matters,  chemic  preservatives,  and 
sophistication  of  every  kind. 

ARTIFICIAL  FOOD  PREPARATIONS 

To  this  class  of  foods  belong  those  preparations  that  are  so  con- 
centrated as  to  furnish  a  large  amount  of  food  in  small  bulk;  being 
of  small  bulk,  they  can  be  added  to  liquid  foods,  and  thus  the  nutri- 
tive value  of  the  latter  increased  without  increasing  the  total  quantity 

lAm.  Jour.  Phvsiol.,  1898,  No.  1. 

2  U.  S.  Dept.  Agriculture,  Bull.  84,  Part  I. 


ARTIFICIAL  FOOD  PREPARATIONS  201 

of  liquid  taken.  The  Council  of  Pharmacy  and  Chemistry  of  the 
American  Medical  Association  has  demonstrated  the  uselessness  of 
many  proprietary  foods  inasmuch  as  when  taken  alone  the  patient 
is  receiving  a  starvation  diet  and  at  the  same  time  paying  an  ex- 
orbitant price  for  the  real  amount  of  nutritive  matter  received.  A 
number  of  these  preparations  have  been  mentioned  under  the  head 
of  beef-juices  and  meat-powders.  The  various  casein  preparations, 
among  which  may  be  mentioned  nutrose,  eucasein,  sanose,  and  plas- 
mon,  are  artificial  foods. 

1.  Nutrose  is  prepared  from  the  casein  of  milk  combined  with  an 
alkali  (sodium),  wiiich  converts  the  casein  into  a  colorless,  tasteless 
powder  completely  soluble  in  water.  It  contains  from  13  to  18  per 
cent,  of  nitrogen,  and  is  used  as  a  food  in  digestive  disturbances.  It 
is  administered  in  soups  (one-third  to  one-half  ounce  of  nutrose  to 
each  cupful). 

2.  Eucasein  is  a  similar  preparation,  in  which,  however,  ammonia 
enters  instead  of  sodium. 

3.  Milk  somatose  is  a  food  prepared  from  milk  casein  and  contains 
5  per  cent,  of  tannic  acid.  It  is  a  yellowish  tasteless  powder.  It  is 
especially  useful  as  an  astringent  food  in  intestinal  catarrh  and 
dysentery. 

4.  Plasmon  is  prepared  from  the  proteins  of  milk,  and  is  a  most 
useful  casein  product.  It  is  a  white  tasteless  powder,  soluble  in 
warm  water.  It  is  administered  in  water,  milk,  or  broths.  It  con- 
tains about  70  per  cent,  of  proteins. 

5.  Galactogen  is  obtained  from  milk.  It  contains  70  per  cent, 
of  protein  and  is  especially  agreeable  as  galactogen-chocolate. 

6.  Mammala. — This  is  pure  cow's  milk  from  which  part  of  the 
cream  has  been  removed  and  milk  sugar  added.  This  is  then  dried  by 
the  Hatmaker  process,  the  result  being  a  yellowish  white,  fluffy  powder 
with  a  very  faint  odor  of  fatty  acids.  Mixed  with  water  it  forms  a 
fluid  very  like  milk  and  very  easily  digested  and  assimilated.  It  is 
useful  in  feeding  infants  and  invalids  where  cow's  milk  does  not 
agree.  For  invalids  one  third  to  three  quarters  of  a  glass  of  mammala 
and  then  filled  with  warm  water  may  be  used.  For  infants  a  heaping 
teaspoonful  to  each  ounce  of  water  and  in  some  cases  from  one 
quarter  to  half  as  much  in  addition  will  be  found  sufficient. 

Artificial  Proteins  made  from  Meat. — A  number  of  these  prepa- 
rations have  already  been  described.  To  this  class  belong:  1. 
Tropon.     2.  Peptone-products.     3.  Ferson.     4.  Somatose. 

1.  Tropon  is  prepared  both  from  animal  and  vegetable  protein  in 
the  form  of  a  powder  containing  about  80  per  cent  of  protein.  It 
is  best  given  in  broth,  milk  or  cocoa. 

2.  Peptone-products. — Peptone-products  are  predigested  protein 
foods.  When  given  in  large  quantities  they  tend  to  produce  diarrhea, 
and  are  objectionable  to  many  patients  on  account  of  their  disagreed- 


202 


VARIOUS  FACTORS  IN  RELATION  TO  DIET 


ble  taste.  Among  the  principal  peptone-products  manufactured  may 
be  mentioned  Kemmerich's,  Koch's,  Benger's,  Savory  &  Moore's, 
Carnrick's,  Armour's  Wine  of  Beef  Peptone,  and  Panopeptoii. 

The  following  table,  taken  from  Konig,  gives  the  chemic  composition 
of  some  peptone  preparations : 


Preparation. 

c 

3     S 

M         p, 

Pep- 
tones. 

other 
nitro- 
genous 
com- 
pounds. 

.a 

Kemmerich's  meat  peptone  (dry) 
Kocli's  meat  peptone  (dry)  .... 
Benger's  peptonized  beef  jelly  .  . 
Savory  &  Moore's  fluid  beef  .   .   . 

33.30 
40.16 
89.68 
27.01 

9.78       1.10 
7.80      1.42 
1.55       .   . 

8.77       .   . 

14.56 

15.95 

2.41 

5.42 

32.57 
18.83 
4.75 
2.74 

9.97 
15.96 

2.27 
52.73 

0.30 
0.79 

7.73 
6.89 
0.89 
12.10 

3.  Ferson  is  ox  blood  from  which  the  blood  corpuscles  are  separated 
from  the  serum,  dried  in  vacuo  and  powdered.  It  is  an  odorless 
powder  containing  considerable  iron  and  phosphorus.  The  prepara- 
tion is  best  taken  in  milk  in  doses  of  from  3  to  4  teaspoonfuls  a  day. 

4.  Somatose. — Somatose  is  a  predigestcd  meat  consisting  of  al- 
bumoses.  It  is  a  yellowish  powder,  tasteless,  odorless,  and  highly 
nutritious,  and  is  usually  well  borne  even  in  gastric  disturbances. 

Artificial  Proteins  prepared  from  Vegetables. — The  two  princi- 
pal forms  of  this  class  of  foods  are  as  follows : 

1.  Roborat. — This  is  a  vegetable  protein  manufactured  from  rice, 
wheat,  and  maize.  It  is  a  fine,  odorless,  and  tasteless  flour,  slightly  ' 
soluble  in  water.  It  is  well  borne  by  the  stomach,  and  is  absorbed 
about  as  well  as  an  animal  albumin  (up  to  95  per  cent.).  It  is  free 
from  nuclein  and  does  not  increase  the  excretion  of  uric  acid.  It 
may  be  added  to  any  food,  but  ordinarily  30  or  40  per  cent,  of  it  is 
mixed  with  flour  and  baked. 

2.  Legumin  consists  of  the  casein  of  the  legumes,  and  is  a  highly 
nutritious  protein  food. 

3.  Aleuronat  is  a  brownish  powder  chiefly  utilized  as  a  food  for 
diabetics.     It  contains  80  per  cent,  of  protein. 

Mixed  Artificial  Food  Preparations. — These  products  are  mix- 
tures of  proteins  and  carbohydrates.  Of  these  the  following  are  most 
important : 

1.  Acorn-cocoa  consists  of  cocoa  from  which  a  large  portion  of  the 
fat  has  been  extracted,  and  to  which  an  extract  of  acorns  has  been 
added.  This  preparation  is  especially  useful  as  an  astringent  in 
diarrheas. 

2.  Hygiama  consists  of  condensed  milk  with  the  addition  of  cereals 
and  cocoa  and   is  highly  nutritious. 

3.  Racahout  is  composed  of  chocolate,  sugar  and  Arabian  meal,  and 
is  nutritious  and  agreeable. 


ARTIFICIAL  FOOD  rKEPAl!ATIOXS!  203 


ARTIFICIAL  PROPRIETARY  FOODS. 

A  large  number  of  proprietary  foods,  designed  as  substitutes  for 
milk  for  infants  and  invalids,  are  on  the  market.  Infants  fed  upon 
sueli  foods  alone  are  apt  to  become  rachitic.  Some  of  these  foods 
have  little  food-value,  especially  the  amylaceous  foods  in  which  the 
starch  has  not  been  predigested.  Man}'  of  these  preparations  contain 
too  little  fat  and  far  too  great  a  proportion  of  carbohydrates.  Ac- 
cording to  Holt,  "when  children  are  fed  upon  foods  lacking  in  fat 
the  teeth  come  late,  the  bones  are  soft,  the  muscles  flabby,"  while 
"children  fed  upon  foods  containing  too  much  sugar  are  frequently 
very  fat,  but  their  flesh  is  very  soft ;  they  walk  late  and  they  perspire 
readily  about  the  head  and  neck."  As  Halliburton  has  recently 
pointed  out,^  "mere  chemic  analysis  is  no  criterion  of  food-value,  for 
the  digestibility  of  the  food  is  the  all-important  question.  Investiga- 
tions into  the  value  of  food-stuffs  must  be  conducted  and  controlled 
both  in  vivo  and  in  vitro — both  in  the  body  and  in  the  test-tube. 
The  results  of  test-tube  experiments  are  of  value,  but  t-he  final  test 
of  food-stuffs  must  be  made  on  animals,  and  preferably  on  man. 
These  experiments  are  both  tedious  and  difficult,  but  there  is  a  growing 
appreciation  of  their  value  and  an  increasing  resort  to  their  use." 

Hutchison  -  divides  proprietary  foods  into  three  classes : 

1.  Foods  prepared  from  cows'  milk  with  various  additions  or 
alterations,  and  requiring  only  the  addition  of  water  to  fit  them  for 
immediate  use.  To  this  class  belong  Malted  ]\Iilk,  Nestle 's  Food, 
Lactated  Food,  Carnrick's  Food,  Cereal  Milk,  Wyeth's  Prepared 
Food,  and  Wampole's  Milk  Food.  These  foods  are  prepared  from 
flour  baked  and  mixed  with  milk  or  cream  and  then  dried.  By  means 
of  the  malt  which  is  added  the  starches  are  converted  into  dextrin 
and  maltose.     The  general  composition  of  these  foods  is  as  follows : 

Per  cent. 

Water   90.0 

Protein    1.0 

Fat    0.5 

Sugar    5.0 

Mineral  matter   0.5 

The  chemic  composition  of  Malted  Milk  and  of  Nestle 's  Food  is 
thus  given  by  Chittenden :  ^ 

Malted  Milk.  Nestle's  Food. 

Water     92.40  92.76 

Protein    . 1.15  0.81 

Fat   0.60  0.36 

Sugar 5.38  3.80 

Mineral  matter    0.29  0.13 

2.  Farinaceous  foods  prepared  from  cereals  of  which  the  starch 

1  "Dietetic  Value  of  Patented  Foods,"  New  York  Med.  Jour.,  January  23,  1904. 

2  Food  and  Dietetics,  p.  445. 

3  New  York  Med.  Jour.,  July  18,  1896. 


204 


VARIOUS  FACTORS  IN  RELATION  TO  DIET 


has  been  partly  or  wholly  converted  into  dextrin  or  sugar,  and 

which  require  the  addition  of  milk  to  fit  them  for  use.  To  this  class 
belong  Mellin's  Food,  Savory  &  Moore's  Infant  Food,  and  Benger's 
Food.  These  foods  are  prepared  by  mixing  equal  parts  of  wheat  flour 
and  barley  malt  with  bran  and  potassium  bicarbonate.  The  mixture 
is  made  into  a  paste  with  water,  and  kept  at  a  warm  temperature 
until  the  starch  is  converted  into  dextrin  and  maltose.  As  these 
foods  are  poor  in  fat,  protein,  and  mineral  matters,  they  are  added 
to  milk  in  order  to  render  them  more  nutritious. 

3.  Farinaceous  Foods  in  which  the  Starch  has  not  been 
Predigested. — To  this  class  belong  Ridge's  Food,  Neave's  Food,  Im- 
perial Granum,  and  Robinson's  Patent  Barley.  These  foods  are  poor 
in  fat,  protein,  and  mineral  matters. 

Cereal  gruels,  frequently  used  in  infant  feeding,  are  most  easily 
made  from  prepared  flours.  They  are  not  always  identical  in  com- 
position, but  the  following  table,  showing  composition  of  gruels  made 
from  the  Cereo  Company  gruel  flours,  is  instructive : 


Barley. 

Legume. 

Oat. 

Wheat. 

Pro-    Carbo. 

Pro-     Carbo. 

Pro-    Carbo. 

Pro-    Carbo. 

teids.  Hydts. 

teids.  Hydts. 

teids.  Hydts. 

teids.  Hydts. 

1  level  tablespoonful  flour 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

(%  oz.)  to  quart  of  gruel  . 

0.12 

0.60 

0.19 

0.53 

0.12 

0.60 

0.10 

0.62 

2  level  tablespoonfuls  flour 

(^oz.)  to  quart  of  gruel  . 

0.24 

1.20 

0.39 

1.06 

0.24 

1.20 

0.20 

1.25 

3  level  tablespoonfuls  flour 

Qi  oz.)  to  quart  of  gruel  . 
1    level    coverful   flour    (1 

0.36 

1.80 

0..58 

1.59 

0..36 

1.80 

0.30 

1.88 

oz.)  to  quart  of  gruel  .  .   . 

0.48 

2.40 

0.78 

2.12 

0.48 

2.40 

0.40 

2.50 

2    level  coverfuls    flour    (2 

oz.)  to  quart  of  gruel  .   .   . 
3    level    coverfuls    flour  (3 

0.% 

4.80 

J. 56 

4.24 

0.98 

480 

0.80 

5.00 

oz.)  to  quart  of  gruel  .   .   . 

1.44 

7.20 

2.34 

6.36 

1.44 

7.20 

1.20 

7.50 

4    level    coverfuls   flour  (4 

oz.)  to  quart  of  gruel  .  .  . 

1.92 

9.60 

3.12 

8.48 

1.92 

9.60 

1.60 

10.00 

Composition  of  Proprietary  Foods. 
(Compiled  from  Hutchison.) 


Food. 

Water. 

Protein. 

Fat. 

Carbohy- 
drate. 

Mineral 
matter. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Allenbury,  No.  1     .    .    .    . 

5.7 

9.7 

14.0 

66.85 

3.75 

Allenbury,  No.  2     .    .    .    . 

3.9 

9.2 

12.3 

72.1 

3.50 

Allenbury,  No.  3     .    .    .    . 

6.5 

9.2 

1.0 

82.8 

0.5 

Bengei-'s  Food 

8.3 

10.2 

1.2 

79.5 

0.8 

Carnrick's  Soluble  Food  . 

5.5 

13.6 

2.5 

76.2 

2.20 

Fairchild's  Milk  Powder  . 

5.54 

1.19 

0.05 

92.0 

1.22 

Horlick's  Malted  Milk  .    . 

3.7 

13.8 

3.0 

76.8 

2.70 

Imperial  Gmnum   .... 

11.50 

10.91 

0.64 

5.73 

1.0 

Mellin's  Food 

6.3 

7.9 

trace 

82.0 

3.8 

Nestle's  Milk  Food     .    .    . 

5.5 

11.0 

4.8 

77.4 

1.30 

Ridge's  Food           .... 

7.9 

9.2 

1.0 

81.2 

0.7 

Robinson's  Patent  Barley  . 

10.1 

5.1 

0.9 

82.0 

1.9 

ARTIFICIAL  FOOD  PREPARATIOXS 


205 


Other  Proprietary  Foods. — Crackers  are  prepared  from  flour, 
water  or  milk,  and  are  baked  into  various  forms.  Baking-powder 
and  soda,  and  frequently  milk,  butter,  sugar,  and  flavoring  extracts, 
are  added.     Crackers  are,  as  a  rule,  easily  digested. 

Malt  Extracts. — Malt  extracts  are  manufactured  by  heating  a  solu- 
tion of  malted  barley  at  a  moderate  temperature  in  vacuo.  The  aver- 
age composition  of  malt  extracts,  as  given  by  Klemperer,^  is  as 
follows  ; 

Per  cent. 

Sugar   50-55 

Soluble  starch    10-55 

Protein 5-6 

Ash 1-2 

Malt  extracts  are  especially  useful  as  beverages  for  those  weakened 
by  chronic  disease,  as  tuberculosis  or  anemia,  and  in  the  convalescence 
from  acute  diseases,  as  after  typhoid  fever  or  pneumonia.  Among 
the  various  malt  preparations  may  be  mentioned  Mai  tine,  Kepler's 
Extract  of  Malt,  and  Holf 's  Malt  Extract. 

The  following  table  gives  the  chemic  composition  of  various  proprie- 
tary foods  manufactured  by  the  Battle  Creek  Sanitarium  Co. : 


Breakfast  foods  and  cereals. 


Gi-anose 

Toasted  wheat  flakes 
Toasted  com  flakes    . 

'rranuto  

Granola 


Glutens: 


Gluten  meal  40  per  cent. 
Gluten  biscuit  40  per  cent. 


Nut  foods : 


Bromose  .  .  . 
Malted  nuts  . 
Nut  butter  .  . 
Nut  meal  .  . 
Almond  butter 
Almond  meal 
Nuttolene  .  . 
Protose  .  .  . 
Meltose  .  .  . 
Potato  meal  . 
Hulless  beans 


Water. 


6.00 
6.00 
5.80 
8.80 
11.40 


8.70 
8.70 


13.40 

2.60 

3.00 

3.00 

4.80 

4.80 

60.00 

64.22 

31.17 

7.10 

8.76 


Albumi- 
nous ele- 
ments. 


11.55 

11.55 

9.00 

11.40 

11.87 


41.10 
41.10 


16.00 
23.70 
29.30 
29.30 
21.00 
21.00 
12.12 
21.60 
3.87 
8.50 
23.62 


Fruit- 
sugar. 


10.00 
20.48 


.35.30 
43.90 


49.61 


Total 
carbohy- 
drates. 


78.50 
78.50 
78.30 
77.57 
72.63 


47.90 
47.90 


44.30 

43.90 
17.10 
17.10 
17.30 
17.30 
6.91 
2.85 
64.52 
80.90 
62.49 


Free  fat. 


1.45 
1.45 
1.90 
2.23 
2.50 


1.10 
1.10 


24.00 
27.50 
46.50 
46.50 
54.90 
54.90 
10.46 
10.23 

0.40 
2.03 


Salb). 


2.50 
2.50 
1.00 
0.80 
1.00 


1.20 
1.20 


1.40 
2.20 
4.10 
4.10 
2.00 
2.00 
1.51 
1.40 
0.44 
8.10 
3.10 


Saccharin. — Saccharin  in  small  quantities  (0.3  gram  per  day  or  less) 
added  to  food  is  probably  without  any  deleterious  efitect.  But  in 
quantities  greater  than  this,  and  especially  over  1  gram  daily,  it  is 
injurious  to  the  human  body.     Saccharin  as  a  sweetening  agent  should 

1  Leyden's  Handbuch  der  Ernahrungstherapie. 


206  VARIOUS  FACTORS  IX  RELATIOX  TO  DIET 

only  be  used  iu  diabetes  or  in  other  diseases  in  which  sugar  is  in- 
jurious. It  should  not  be  added  to  foods  for  healthy  individuals. 
It  should  be  borne  in  mind  that  saccharin  has  no  food  value.  For 
full  details  concerning  Saccharin,  see  Report  No.  94,  issued  November 
15   1911,  U.  S.  Department  of  Agriculture. 

COOKING  OF  FOODS 

The  cooking  of  food  is  an  art  practised  by  all  races,  savage  as  well 
as  civilized.  Food  is  cooked  to  improve  its  flavor,  to  soften  it  so 
that  it  can  be  masticated  and  more  easily  digested,  and  finally  to 
destroy  all  parasites  and  disease  germs  that  may  be  present  in  the 
raw  food.  By  cooking,  certain  flavors  are  developed,  which  by  their 
savoriness  increase  the  appetite  and  the  taste  for  the  food.  Cooking, 
moreover,  destroys  the  tough  fibrous  envelopes  that  surround  many 
foods,  thus  permitting  the  food  to  be  more  easily  acted  upon  by  the 
various  digestive  fluids.  Various  parasitic  organisms  present  in  many 
foods  are  destroyed  by  cooking,  and  the  food  thus  freed  from  one 
of  its  most  dangerous  elements.  On  cooking,  the  protein  in  food 
coagulates ;  under  the  influence  of  dry  heat  the  starches  are  gradually 
converted  into  dextrin,  whereas  under  the  influence  of  moist  heat 
the  granules  gradually  swell  until  they  rupture  their  envelopes. 
Sugars  by  boiling  are  changed  gradually  into  caramel,  which  is  the 
source  of  the  odor  frequently  given  off  in  the  cooking  of  food.  "When 
fats  are  heated,  they  undergo  a  change,  with  the  production  of  free 
fatty  acids,  which  are  often  responsible  for  the  odors  that  exist  in  the 
kitchen. 

Cooking  of  Meat. — Boiling. — In  cooking  meats  the  temperature 
of  the  water  should  not  exceed  the  temperature  necessary  for  the 
coagulation  of  the  proteins.  In  order  that  the  meat  may  retain  as 
much  of  its  flavor  as  possible  it  should  be  immersed  in  boiling  water 
for  a  few  moments ;  in  this  way  the  protein  on  the  surface  immediately 
coagulates,  thus  preventing  escape  of  the  constituents  and  so  retaining 
all  the  nutritive  elements  in  the  meat.  After  this  has  been  accom- 
plished the  temperature  of  the  water  may  be  lowered  and  the  process 
of  cooking  continued.  The  broth  which  is  so  produced  is  thin  and 
poor.  If  a  rich,  nutritious  broth  is  desired,  the  meat  should  be  cut 
into  small  pieces  and  placed  in  cold  water,  and  the  temperature 
gradually  increased  to  150°  F.  In  this  way  the  nutritious  elements 
of  the  meat  pass  out  into  the  broth. 

Roasting. — In  roasting,  the  meat  is  first  exposed  to  a  high  tem- 
perature and  afterward  cooked  slowly;  thus  the  outer  layers  coagulate 
at  once,  preventing  escape  of  the  .iuices.  Roasting  not  only  prevents 
evaporation  of  the  flavors  of  meats,  but  by  its  effect  on  the  extractives 
develops  savory  odors  and  flavors. 

Baking. — Baking  much  resembles  roasting,  except  that  by  the  latter 


COOKlXa  OF  FOODS  207 

process  the  heat  is  applied  all  round  the  meat,  instead  of  only  to  one 
side. 

Stewing. — For  this  purpose  meat  is  cut  into  small  pieces  and  placed 
in  a  small  (juautity  of  water.  The  water  is  heated  slowly,  but  not 
allowed  to  boil ;  a  certain  amount  of  the  nutritious  substances  thus 
pass  into  the  water,  which  then  becomes  rich,  and  to  which  flavoring 
substances  and  vegetables  are  added.  Inasmuch  as  the  juice  is  eaten 
with  the  meat,  none  of  the  nutritious  ingredients  is  lost. 

Brazing. — In  this  process  the  meat  is  placed  in  a  small  vessel  and 
covered  with  a  strong  liquor  of  vegetable  and  animal  juices;  it  is  then 
heated,  but  not  boiled.  The  tough  fibers  of  the  meat  are  thus  loosened 
and  made  tender;  the  meat  also  becomes  impregnated  with  vegetables 
and  spices  present  in  the  juices,  which  enhances  its  flavor. 

Broiling. — Broiling  and  roasting  are  similar  processes,  except  that 
in  the  former  smaller  portions  are  utilized;  the  process  is  thus  more 
rapid,  a  large  surface  being  exposed  to  the  direct  action  of  the  heat. 

Frying. — In  this  process  the  meat  is  put  into  boiling  fat,  with  which 
it  becomes  saturated ;  fatty  acids  are  thus  produced,  which  have  a 
tendency  to  irritate  the  stomach  and  cause  indigestion. 

Cooking  of  Fish. — Fish  may  be  boiled,  broiled,  baked,  and  fried. 
Boiled  fish  is  most  easily  digested.  Inasmuch  as  the  flavoring  sub- 
stances are  more  easily  dissolved  out  into  the  water  and  lost,  less 
time  should  be  consumed  in  boiling  fish  than  in  boiling  meat.  Sir 
Henry  Thompson  has  shown  that  even  with  careful  boiling  5  per 
cent,  of  the  solid  matter  of  fish  is  apt  to  be  lost;  for  this  reason 
steaming  is  often  preferable. 

EFFECT  OF  COOKING 

The  effect  of  cooking  on  meat  is  to  diminish  its  watery  con- 
stituents, thus  concentrating  and  rendering  it  more  nutritious;  by 
this  process  also  the  extractives,  as  well  as  some  of  the  fats,  are  partly 
removed. 

Grindley  and  Majonnier  have  studied  the  effect  of  cooking  meat 
very  carefully.  They  have  determined  that  the  chief  loss  in  weight 
during  boiling,  sauteing,  and  pan  broiling  is  due  to  water  removed 
by  the  heat  of  the  cooking.  In  the  roasting  of  meats  the  chief  loss 
is  due  to  the  removal  of  both  water  and  fat.  In  pan  broiling  the 
losses  which  take  place  are  very  small  as  compared  with  the  other 
methods  of  cooking.  When  beef  is  cooked  in  water,  from  3.25  to  12 
per  cent,  of  the  nitrogenous  matter,  0.60  to  37  per  cent,  of  the  fat, 
and  20  to  67  per  cent,  of  the  mineral  matter  of  the  original  uncooked 
meat  may  be  found  in  the  broth.  This  nutritive  material  is  not  lost 
in  case  the  broth  is  utilized  with  the  meat.  In  roasted  meats  from 
0.25  to  4.55  per  cent,  of  nitrogenous  matter,  4.5  to  57  per  cent,  of 


208  VARIOUS  FACTORS  IX  RELATION  TO  DIET 

fat,  and  2.4  to  27  per  cent,  of  mineral  matter  present  in  the  uncooked 
meat  may  be  found  in  the  drippings.  Beef  which  has  been  used  in  the 
preparation  of  beef-tea  or  broth  has  really  lost  but  comparatively  lit- 
tle in  nutritive  value,  although  much  of  the  flavoring  matter  has 
been  removed.  The  longer  time  meat  is  cooked,  and  the  higher 
temperature  at  which  this  is  done,  the  greater  the  loss  in  water  and 
fat,  the  larger  pieces  losing  relatively  less  than  the  smaller  ones.  A 
point  of  considerable  interest  is  that  when  meat  is  cooked  in  water 
at  80°  to  85°  C,  placing  the  meat  in  hot  or  cold  water  at  the  start, 
has  but  little  effect  on  the  amount  of  material  found  in  the  broth. 

The  following  table,  taken  from  Konig,  shows  the  chemic  composi- 
tion of  certain  meats  before  and  after  cooking : 

^^'-t--  ""'Zlf^eT'            Fat.  Extractives.  Se7.' 

Beef,  raw   70.88             22.51               4.52               0.8G  1.23 

Beef   boiled    56.82             34.13               750               0.40  1.15 

Beef  roasted    55.39             34.23               8.21               0.72  1.45 

Veal  cutlets,  raw 71.55               6.93               6.38               0  68  1.15 

Veal  cutlets  roasted 57.59             11.95  1195               0.03  1.43 

Effect  of  Cooking  on  Vegetables. — The  important  object  in  the 
cooking  of  vegetables  is  to  rupture  the  cellulose  envelop  and  so  to 
soften  the  contained  starch-granules.  Under  the  influence  of  heat 
and  moisture  the  starch  swells  and  bursts  its  envelop,  forming  a 
paste;  this  paste,  in  its  turn,  expands  and  ruptures  the  cellulose 
envelop;  cooking,  therefore,  renders  vegetable  foods  more  digestible. 

As  has  been  pointed  out,  in  the  cooking  of  meats  a  certain  propor- 
tion of  the  ingredients  is  lost.  Unlike  meats,  however,  vegetables 
become  more  watery  in  cooking.  In  this  condition  they  are  more 
easily  acted  upon  by  the  gastric  secretion ;  on  the  other  hand,  the 
addition  of  water  in  cooking  so  increases  their  bulk  that  the  motor 
function  of  the  stomach  is  apt  to  be  over-taxed. 

When  food  is  cooked  rapidly  there  is  a  tendency  to  overcook  the 
outer  layers  and  to  leave  the  inner  underdone.  The  better  plan, 
therefore,  is  to  cook  food  slowly  for  a  longer  period  of  time  at  a  lower 
temperature.  Various  appliances  are  on  the  market  which  have  for 
their  object  the  production  of  a  continuous  action  of  a  moderate  heat, 
at  the  expense  of  as  little  fuel  as  possible,  the  "Aladdin  Oven"  of 
Dr.  Edward  Atkinson  ^  is  an  apparatus  of  this  kind.  "It  is  a  simple 
iron  box,  closed  in  front  by  a  door,  and  having  an  opening  in  the 
top  that  communicates  with  a  tube  to  let  off'  any  superfluous  steam. 
This  box  is  surrounded  by  another,  whose  top  and  sides  are  made  of 
non-conducting  material,  for  the  purpose  of  holding  the  heat.  A 
standard,  on  which  this  box  is  set,  and  a  lamp  underneath  complete 
the  apparatus."  Atkinson  claims  that  ordinarily  two  pounds  of  fuel 
are  required  for  every  pound  of  food  cooked,  whereas  with  his  oven 

1  Edward  Atkinson,  The  Science  of  Nutrition  and  the  Art  of  Cooking  in  the 
Aladdin  Oven,  Boston,  Damrell  &  Upham,  1896. 


I 


DISEASES  CAUSED  BY  ERRORS  IX  DIET  209 

two  and  one-half  pounds  of  fuel  will  cook  sixty  pounds  of  food. 
Canon  More  Ede,  of  England,  invented  a  similar  apparatus  for  tlie 
cooking  of  penny  meals.^     He  describes  his  apparatus  as  follows : 

"It  consists  of  a  box  3  feet  high,  2  feet  wide,  1  foot  9  inches  deep, 
with  an  outer  case  of  sheet  iron.  The  sides  and  lid  are  lined  with  2i/^ 
inches  of  felt,  and  inside  this,  again,  is  a  further  lining  of  tin.  Un- 
derneath this  box,  which  will  hold  30  gallons,  are  placed  two  of 
Fletcher's  atmospheric  gas-burners.  The  felt  being  a  non-conductor, 
nearly  all  the  heat  from  the  gas  is  utilized,  and  a  comparatively  small 
expenditure  of  gas  suffices  to  raise  the  temperature  of  the  contents  of 
the  box  to  boiling-point,  or  to  the  heat  required  for  the  food  which 
is  being  cooked. 

"When  once  the  desired  temperature  is  obtained,  one  of  the  burners 
can  be  turned  off  and  the  other  lowered,  when,  owing  to  the  preven- 
tion of  radiation  by  the  felt,  it  will  be  found  that  a  merely  nominal 
expenditure  of  gas  will  enable  the  temperature  to  be  maintained  for 
hours,  and  even  when  the  gas  is  totally  extinguished,  many  hours  will 
elapse  before  food  cooked  will  become  cool. 

"But,  except  in  the  case  of  puddings  which  require  rapid  boiling, 
the  cooking  is  done  in  an  inner  pan,  which  is  placed  inside  the  box, 
and  which  contains  rather  more  than  twenty  gallons.  The  apparatus 
may  be  best  described  as  a  huge  Warren's  pot,  with  the  additional 
advantage  that  the  whole  of  the  inner  pan  is  surrounded  by  warm 
water. ' ' 

DISEASES  CAUSED  BY  ERRORS  IN  DIET  AND  BY 
VARIOUS  FOOD-POISONS 

Disease  may  be  caused  by  taking  too  little  or  too  much  food,  by 
a  diet  that  is  not  well  balanced, — that  is,  does  not  contain  the  combina- 
tion of  food-elements  in  correct  proportions, — and  by  other  factors 
and  influences  the  precise  nature  of  many  of  which  is  obscure.  It 
may  also  be  caused  by  certain  poisons  or  disease-germs  or  parasites 
taken  into  the  body  with  the  food  or  drink.  Disease  may  occasionally 
be  produced  by  a  personal  food  idiosyncrasy.  It  is  also  frequently 
caused  bj'  certain  beverages. 

The  diseases  due  to  the  taking  of  insufficient  food  are  starvation, 
malnutrition,  marasmus,  and  some  forms  of  anemia.  Chlorosis  is  apt 
to  occur  in  underfed  girls. 

Overeating,  or  the  taking  of  improper  food,  gives  rise  to  a  great 
variety  of  diseases,  especially  in  those  who  have  hereditary  tendencies 
to  certain  diseases.  The  food,  by  producing  irritation  in  the  ali- 
mentary tract,  may  be  the  direct  cause  of  disease,  as  in  acute  indiges- 
tion, diarrhea,  and  the  like.  Disease  may  also  be  produced  by  the 
excessive  amounts  of  food  assimilated  either  being  deposited  as  fat 

1  Cheap  Food  and  Cheap  Cooking,  London,  Walter  Scott,  1884. 
14 


210  VARIOUS  FACTORS  IN  RELATION  TO  DIET 

and  causing  obesity,  or  by  overworking  the  organs  of  excretion,  pro- 
ducing degenerations  or  scleroses.  The  kidneys,  liver,  and  heart  are 
the  organs  most  likely  to  suffer,  but  the  nervous  system  may  also  be 
affected.  In  epileptics  attacks  may  be  brought  on  by  overfeeding. 
Gout,  lithemia,  and  the  like  are  among  the  diseases  caused  by  a  too 
generous  diet.  Diseases  of  the  skin,  such  as  acne,  eczema,  and  urti- 
caria, may  also  have  the  same  causal  factor. 

Overeating  is  probably  as  prolific  a  source  of  disease  as  overdrink- 
ing, a  fact  that  is  not  generally  admitted.  The  commonest  effects  of 
overdrinking  are  the  nervous  conditions  caused  by  excessive  tea-  or 
coft'ee-drinking,  and  the  all  too  familiar  condition,  with  its  well-known 
symptomatology,  of  acute  or  chronic  alcoholism. 

Acute  food-poisoning  is  due  to  the  action  of  ptomains,  and  is  often 
known  as  ptomain-poisoning.  Ptomains,  or  toxins,  are  poisonous  sub- 
stances caused  by  the  action  of  bacteria,  and  may  be  generated  in 
nitrogenous  foods  or  in  the  alimentary  tract.  They  resemble  alka- 
loids, and  when  absorbed  are  partially  destroyed  in  the  liver. 

Parasites  in  Food  or  Drink. — Quite  a  number  of  diseases  are  com- 
municated to  man  through  either  the  parasite  or  its  embryo  being 
taken  into  the  stomach  with  the  food  or  in  drinking-water.  For  a 
thorough  knowledge  of  these  parasites  and  their  effects  on  the  human 
system  the  student  is  referred  to  the  text-books  on  bacteriology. 

The  Amoeba  coli,  which  causes  a  form  of  chronic  dysentery,  is 
probably  taken  in  with  the  drinking-water.  Its  life-history  is  not 
definitely  known. 

Coccidium  Oviforme. — ^The  spores,  known  as  psorospermia,  have  been 
found  in  the  liver,  pleura,  and  other  organs  of  man.  They  probably 
gain  entrance  into  the  system  from  water,  green  vegetables,  or  from 
handling  animals  such  as  dogs  and  rabbits.  The  life-history  of  this 
organism  is  obscure. 

Trichomonas  ^  and  cercomonas  are  small  parasites  at  times  found  in 
the  stools. 

Distoma  hepaticum,  or  liver  fluke,  usuallj^  infests  the  gall-duct  or 
the  gall-bladder.  The  embryos  are  attached  to  aquatic  plants,  and 
hence  are  believed  to  be  taken  in  with  them  or  with  drinking-water. 
Several  other  species  are  described  as  occurring  in  China  and  in 
Egypt. 

Bilharzia  haematobia,  or  blood  fluke,  is  found  in  the  urine.  It  is  a 
native  of  Egypt,  southern  Africa,  and  Arabia.  The  embryos  are 
probably  taken  into  the  body  with  drinking-water. 

Tapeworm. — Several  species  of  tapeworm  have  been  described.  The 
neck  and  head  of  this  worm,  called  the  scolex,  may  become  encysted, 
and  the  worm  is  then  known  as  the  ej'Sticercus. 

Tcenia   Solium.— The   pork   tapeworm   is   a   somewhat   rare   form,. 

1  For  a  description  of  the  trichomonas,  see  Dock,  Amer.  Jour.  ^led.  Sci.,  1896, 
vol.  cxi.,  p.  1. 


DISEAiiEIS  VALUED  BY  EKIiOlii^  IX  DIET  211 

infection  usually  taking  place  by  means  of  the  embryos  present  in 
raw  or  underdone  pork.  The  embryos  are  seen  in  the  meat  as  small 
white  spots,  and,  from  its  mottled  appearance,  the  meat  containing* 
them  is  usually  called  measly  pork.  Government  inspection  of  meat 
has  done  much  to  prevent  infection  by  this  and  other  forms  of 
parasites. 

Tcenia  mediocanellata  or  saginata  is  the  most  common  tapeworm  in 
the  United  States.  Infection  is  produced  through  eating  raw  or 
underdone  beef.     There  are  several  other  rare  varieties : 

Toenia  cucumerina  or  elliptica,  a  very  small  tapeworm,  is  found  in 
the  dog  and  occasionally  in  man.  Its  embryos  occur  in  the  dog 
louse. 

Taenia  flavopunctata  is  a  form  found  in  Boston. 

Tcenia  nana  and  madagascariensis  are  forms  occasionally  met  with. 

Bothriocephalus  latus  is  a  tapeworm  found  in  the  north  of  Europe, 
but  is  occasionally  imported  into  the  United  States.  The  larva^  are 
found  in  fish.  Two  other  forms,  B.  maritima  and  B.  mystax,  have 
been  found  in  man.  B.  cordaius,  seen  in  Greenland,  and  B.  Cristalus 
are  other  rare  forms;  the  former  was  found  in  an  immature  state  in 
Iceland  and  the  latter  usually  occurs  in  cats  or  dogs. 

TcBuia  Echinococcus. — This  is  found  in  the  intestines  of  dogs.  In 
man  it  may  form  single  or  multilocular  cysts.  Infection  occurs  from 
handling  dogs  or  from  eating  green  vegetables.  It  is  rare  in  America, 
but  not  uncommon  in  Europe. 

Ascaris  lumbricoides,  or  round-worm,  is  a  common  parasite  whose 
life-history  is  unknown. 

Oxyuris  vermicularis,  or  pin-worm,  a  small  parasite  often  found  in 
children,  is  believed  to  be  taken  in  with  fruit  and  other  raw  food. 

Strongylus  duodenale,  also  called  Anchylostomum  duodenale,  is  a 
parasite  attracting  considerable  attention  in  America.  Formerly  but 
little  known  in  the  United  States,  numerous  instances  of  infection  by 
this  parasite  have  recently  been  reported.  It  is  a  small  parasite,  from 
6  to  10  millimeters  long,  and  is  present  in  the  upper  part  of  the  in- 
testine. It  causes  severe  anemia.  The  embryos  of  the  parasite  are 
probably  taken  in  with  drinking-water.  It  is  apt  to  occur  in  brick- 
makers,  miners,  and  those  following  similar  occupations. 

Filaria  Sanguinis  Hominis. — This  parasite  is  found  in  the  Southern 
States,  and  is  probably  also  taken  with  impure  water.  It  causes 
hematochjduria  and  certain  forms  of  elephantiasis. 

Filaria  or  Dracunculus  medinensis,  or  guinea-worm,  develops  in  the 
Cyclops,  a  small  crustacean.  The  larvae  are  probably  taken  into  the 
stomach  with  drinking-water.  It  causes  vesicles  and  ulcers.  Cases 
of  infection  that  must  have  occurred  in  America  have  been  described. 

Trichocephalus  dispar,  or  whipworm,  is  found  in  the  cecum,  and  is 
about  4  or  5  centimeters  in  length.  It  does  not,  as  a  rule,  cause  any 
symptoms. 


212  VARIOUS  FACTORS  IX  RELATION  TO  DIET 

Rhabdonema  intestinale  is  a  small  parasite  ofteu  spoken  of  as  the 
Coehiu-China  diarrhea  worm.  It  is  found  in  the  intestines,  and 
causes  a  form  of  tropical  diarrhea.  It  has  been  discovered  in  many 
parts  of  the  world. 

Parasitic  Diseases. — Trichiniasis. — This  is  a  disease  caused  by 
eating  the  so-called  "measly"  pork,  or  pork  infected  with  Trichina 
spiralis.  This  parasite  measures  1.5  millimeters  in  length — the 
female,  3  to  3.5  millimeters,  and  the  embryos  from  0.5  to  1  millimeter. 
The  embryos  are  generally  coiled  up  and  encapsulated,  and  are  seen 
in  the  voluntary  muscles,  giving  rise  to  the  name  mentioned  above. 
The  parasite  is  also  found  in  the  rat,  and  Dock  believes  that  the 
disease  is  communicated  to  the  hog  by  eating  infected  rats. 

AVhen  taken  into  the  intestinal  canal,  the  envelop  surrounding  the 
embryo  is  dissolved,  and  in  from  three  to  six  days  the  latter  develops 
into  a  full-grown  trichina.  The  female  produces  the  embryos  by 
thousands,  and  these  work  their  way  through  the  intestinal  wall  and 
enter  into  the  voluntary  muscles,  where  they  may  be  found  several 
weeks  after  infection.  If  thej^  are  to  be  found  at  all,  they  are  present 
in  the  diaphragm,  which,  owing  to  its  proximity  to  the  intestinal 
canal,  is  the  favorite  site.  In  the  muscles  the  parasites  are  surrounded 
by  a  zone  of  irritation,  and  finally  become  encapsulated,  lime  salts 
being  deposited  in  the  capsule.  Thus  encapsulated,  the  parasite  may 
live  for  years.  Its  presence  gives  rise  to  gastro-intestinal  irritation, 
fever,  pain,  and  prostration.  There  is  frequently  a  picture  simidating 
typhoid.  A  marked  eosinophilia  is  usually  present,  and  the  disease 
proves  fatal  in  many  cases. 

Owing  to  the  greater  frequency  witli  which  raw  pork  is  eaten  in 
Germany,  trichiniasis  is  commoner  in  that  country  than  in  the  United 
States.  A  temperature  of  140°  F.  kills  the  parasite,  and  the  only 
sure  way  of  preventing  the  disease  is  to  cook  all  pork.  The  presence 
of  the  parasite  is  easily  detected,  and  in  places  where  meat  is  inspected 
infected  meat  should  be  rejected  by  the  Government  inspector. 
Pickling  and  curing  meat  may,  if  the  pieces  are  thin,  kill  the  parasites, 
but  they  may  survive  if  the  pieces  of  meat  are  large. 

Diseases  from  Milk. — Numerous  diseases  are  transmitted  through 
the  agency  of  milk,  the  cow  itself  being  diseased  or  subsequent  con- 
tamination of  the  milk  taking  place.  The  cow  may  be  suffering  from 
diseased  udders  or  from  some  affection  of  the  mammary  gland.  The 
organism  most  commonly  present  in  infected  milk  is  the  streptococcus. 
Tubercle  bacilli  may  find  their  way  into  the  milk  from  a  diseased 
gland  or  udder.  As  a  rule,  it  may  be  stated  that  if  the  disease, 
whatever  it  may  be,  is  not  in  the  mammary  gland  or  in  the  udder,  it 
is  unlikely  that  the  bacteria  which  gave  rise  to  the  disease  will  find 
their  way  into  the  milk.  It  should  be  borne  in  mind,  however,  that 
milk  from  a  sick  cow,  even  if  it  does  not  cause  disease  directly,  is  apt 
to  be  poor  in  quality,  and  is  not  desirable  for  food. 


DISEASES  CAUSED  BY  ERRORS  IX  DIET  213 

Milk  infectiou  is  most  commonly  the  result  of  impure  milk,  made 
so  by  improper  care  and  contamination  with  toxin-producing  bacteria. 
The  disease  may  be  the  result  of  toxins  formed  in  the  milk,  or  the 
bacteria  themselves  may  be  the  cause  of  the  disturbance.  (For  de- 
tails as  to  the  proper  care  of  this  food,  see  the  section  on  Milk.) 
Sour  milk  or  milk  which  is  about  to  turn  may  cause  gastric  or  in- 
testinal disturbances  in  invalids  or  children. 

Poisons  Transmitted  in  Milk. — Poisonous  substances  taken  in  with 
the  food  of  the  animal  or  administered  in  sufficient  quantities  as 
remedies  may  be  transmitted  in  the  milk  and  cause  symptoms  in  the 
consumer.  This  is  not  of  very  frequent  occurence.  Among  the 
numerous  drugs  which  have  been  reported  as  causing  poisonous 
symptoms  are :  arsenic,  lead,  copper,  mercurj",  tartar  emetic,  iodin, 
atropin,  veratrum  viride,  strychnia,  croton  oil,  and  others. 

Tuberculosis. — Milk  as  a  cause  of  tuberculosis  has  of  late  years  been 
the  subject  of  much  discussion.  This  discussion  was  largely  the 
result  of  a  statement  made  by  Koch,  in  1901,  that  bovine  tuberculosis 
could  not  be  transmitted  to  man,  and  that  the  disease  as  found  in 
man  and  in  animals  was  due  to  two  different  organisms.  This  state- 
ment has  not  been  borne  out  by  facts,  and  it  may  with  safety  be 
stated  that  the  disease  in  both  man  and  animals  is  due  to  the  same 
organism,  although  some  differences  in  the  disease  and  also  in  the 
organism  as  found  in  man  and  in  animals  exist.  If  a  cow  has  tuber- 
culosis of  the  mammary  gland  or  of  the  udder,  although  the  disease 
may  not  be  apparent  to  the  naked  eye,  the  milk  will  contain  tubercle 
bacilli.  If  the  disease  occurs  elsewhere  in  the  body,  tubercle  bacilli 
are  not  apt  to  find  their  way  into  the  milk.  The  tubercle  bacillus, 
moreover,  does  not  multiply  in  milk.  Tuberculosis  may  be  produced 
in  man  by  the  same  bacillus  that  causes  bovine  tuberculosis.  Where 
this  has  occurred,  it  has  usually  been  the  result  of  accident,  the 
disease  following  being  of  a  local  nature  and  of  no  great  intensity. 
Bovine  tubercle  bacilli  have  been  found  in  milk  with  varying  degrees 
of  frequency  by  numerous  observers  and  it  has  been  estimated  by  Park 
and  others  that  some  8  or  10  per  cent,  of  human  tuberculosis  is  due  to 
this  type  of  organism. 

Diarrheal  Diseases. — The  question  of  diarrheal  diseases  as  caused 
by  milk  is  of  the  greatest  practical  importance.  Diarrheal  disease  is 
commonest  in  the  warm  months,  and  97  per  cent,  of  the  eases  that 
occur  in  children  are  in  bottle-fed  babies.  Where  the  milk  is  pure 
and  where  proper  care  has  been  observed  in  transmission  from  the 
cow  to  consumer,  the  disease  is  rare.  AVhere  the  milk  is  impure  and 
is  carelessly  handled,  many  cases  of  diarrhea  and  death  are  the  result. 
These  diseases  may  be  produced  by  toxins  generated  in  the  milk  by  the 
bacteria,  or  bj'  the  bacteria  themselves  being  introduced  into  the 
intestinal  tract.  It  is  not  definitely  known  just  what  bacteria  gives 
rise  to  summer  diarrhea.     The  disease  is  probably  due  to  different 


214  VARIOUS  FACTORS  IX  RELATION  TO  DIET 

organisms.  Recent  investigations  point  to  Bacillus  dysentericus 
(Shiga)  as  the  organism  most  commonly  present.  There  is  no  greater 
lesson  to  be  learned  in  the  whole  range  of  milk  infections  than  that 
impure  milk  causes  diarrhea. 

Diphtheria. — Diphtheria  bacilli  may  find  their  way  into  milk  from 
the  milker,  who  may  have  the  disease  in  a  mild  form,  or  from  sub- 
sequent contamination.  A  number  of  epidemics  have  owed  their 
origin  to  infected  milk. 

Scarlet  Fever. — Where  epidemics  of  this  disease  have  occurred  as 
the  result  of  milk  infection,  they  have  usually  been  traced  to  a  case 
of  the  disease  in  a  milker's  family.  Kober  tabulated  99  scarlet  fever 
epidemics  as  follows :  disease  at  dairy  or  milk  farm,  68 ;  persons  em- 
ployed at  the  dairy  either  lodged  in  or  had  visited  infected  houses,  6 : 
from  infected  bottles  or  milk  cans  left  in  scarlet  fever  houses,  2 ; 
employees  working  while  suffering  or  recovering  from  the  disease, 
17 ;  employees  acting  as  nurses,  10 ;  milk  stored  in  or  near  the  sick- 
room, 3 ;  infected  cloth  used  in  wiping  cans,  1.  In  19  instances  the 
infection  was  attributed  to  inflammation  of  the  udder  or  to  puerperal 
fever  in  the  cow.  These  outbreaks  should  be  regarded  as  cases  of 
streptococcus  or  staphylococcus  infection  rather  than  scarlet  fever. 

Typhoid  Fever. — Many  epidemics  of  typhoid  fever  may  be  traced  to 
an  infected  milk  supply.  Too  much  stress  can  not  be  laid  on  the 
importance  of  investigating  dairy  farms  as  a  source  of  typhoid  fever 
epidemics.  Kober  tabulated  195  epidemics  caused  by  milk.  In  67 
instances  the  milk  was  probably  infected  by  using  infected  well-water 
to  wash  the  utensils,  and  in  16  of  these,  infected  water  had  been 
intentionally  added  to  the  milk  for  purposes  of  dilution.  In  7  in- 
stances the  infection  was  attributed  to  cows  wading  in  sewage-polluted 
water  or  pastures;  in  24  instances  the  dairy  employees  acted  as 
nurses ;  in  10  instances  patients  suffering  with  mild  attacks  continued 
at  work ;  in  1  instance  the  milk-cans  were  washed  with  the  dishcloth 
used  among  the  fever  patients;  in  2  instances  dairy  employees  were 
connected  with  the  night  soil  service ;  and  in  2  instances  the  milk 
had  been  kept  in  a  closet  in  the  sick-room. 

Asiatic  Cholera. — This  disease  may  be  transmitted  through  the 
agency  of  milk,  but  the  usual  mode  of  infection  is  through  drinking- 
water. 

Milk-poisoning  (Galactotoxismus).- — In  1885  tyrotoxicon  was  found 
in  milk,  and  in  1886  Newton  and  Wallace  reported  interesting  series 
of  cases  of  poisoning  due  to  the  presence  of  this  toxin  in  milk.  The 
milk  was  obtained  from  a  dairy  in  which  the  milking  was  done  at 
midnight  and  at  noon.  The  noon  milk  was  the  one  that  was  poison- 
ous. While  still  warm  it  was  placed  in  cans,  and  delivered  to  the 
consumers  in  the  heat  of  the  day.  The  heat  permitted  the  growth 
of  bacteria  which  caused  the  formation  of  toxin.  There  have  been 
numerous  instances  where  its  presence  in  milk  has  caused  poisoning. 


DI8EASE8  CAUSED  BY  ERRORS  /A'  DIET  215 

Vaughaii  and  Novy  have  also  found  it  in  ice-cream  and  in  custard. 
^Shearer  has  demonstrated  its  presence  in  vanilla  and  lemon  ices. 
Besides  tyrotoxicon,  other  toxins  have  been  found  in  milk.  Vaughan 
and  Perkins  have  isolated  a  toxin,  caused  by  a  colon-like  bacillus, 
wiiifh  produces  marked  symptoms. 

Cheese-poisoning  (Tyrotoxismus). — As  early  as  1827  theories  be- 
gan to  be  disseminated  as  to  the  reason  why  some  cheese,  usually 
apparently  unaltered  so  far  as  ordinary  observation  went,  should 
cause  poisoning.  Hiinnefeld  and  others  after  him  believed  it  to  be 
due  to  the  fatty  acids.  Numerous  cases  were  reported  and  discussed. 
In  1888  and  1884  about  300  cases  of  cheese-poisoning  were  reported 
to  the  Michigan  State  Board  of  Health.  All  who  ate  of  the  cheese 
were  attacked,  and  the  symptoms  varied  with  the  quantity  taken, 
being  more  severe  where  large  amounts  had  been  ingested.  The 
symptoms  were  vomiting  and  purging,  with  watery  stools;  the  tongue, 
at  first  white,  then  became  red  and  verj^  dry,  and  there  was  pain 
in  the  region  of  the  stomach.  The  pulse  was  feeble  and  irregular, 
and  in  some  instances  there  was  cyanosis.  Vaughan  studied  these 
cases,  and  found  that  the  poisoning  was  due  to  twelve  different 
varieties  of  cheese,  most  of  which  came  from  one  factory.  The 
cheese  seemed  to  differ  but  little  from  ordinarj^  good  cheese,  but  if 
offered  to  cats  or  dogs  together  Math  good  cheese,  the  animals  in- 
variably chose  the  good.  If  fed  to  hungry  cats,  they  would  eat  it 
and  apparently  with  no  ill  effects.  The  poison  was  isolated,  and 
consisted  of  a  crystalline,  highly  poisonous  substance,  which  Vaughan 
called  tyrotoxicon.  Tyrotoxicon,  however,  appears  to  be  a  compara- 
tively rare  poison,  and  other  toxic  substances  have  been  discovered  in 
cheese.  Vaughan  isolated  an  albumose ;  Vaughan  and  Perkins,  two 
bacilli ;  and  Vaughan  and  McClymonds,  a  bacillus  of  the  colon  group, 
all  of  which  were  toxic. 

Typhoid  Fever  and  Oysters. — Typhoid  fever  has  been  transmitted 
by  infected  oysters,  the  oysters  having  usually  been  grown  very  near 
the  outlet  of  a  sewer  or  on  artificial  beds.  In  New  Haven,  some  years 
ago,  thirty  students  were  infected  with  typhoid  by  eating  raw  oysters 
supplied  by  a  dealer  who  made  a  practice  of  placing  the  fresh  oysters 
in  the  river  for  a  day  or  two  after  receiving  them.  Running  from 
his  house  to  the  river,  near  where  he  had  placed  the  oysters,  was  a 
drain-pipe.  His  daughter  had  typhoid  at  the  time,  and  his  wife  had 
died  of  the  disease  shortly  before.  Instances  have  been  reported  in 
other  countries,  but  it  is  not  a  very  common  mode  of  infection. 

Poison  from  Mussels  (Mytilotoxismus). — According  to  Vaughan 
and  Novy,  there  are  three  kinds  of  mussel-poisoning: 

1.  Where  the  principal  symptoms  are  gastro-intestinal,  and  of  vary- 
ing intensity.  This  form  may  at  times  be  choleriform  (Combe). 
Death  may  follow  very  rapidly — in  Combe's  case  it  occurred  in  two 
davs. 


216  VARIOUS  FACTORS  IN  RELATIONS  TO  DIET 

2.  The  most  frequent  form  is  that  in  which  symptoms  are  prin- 
cipally nervous,  coming  on  shortly  after  the  mussels  are  eaten.  There 
is  a  sensation  of  heat  and  itching ;  a  rash  of  an  urticarial  nature,  and 
sometimes  vesicular,  appears.  There  may  be  dyspnea,  and  death 
■nay  result  from  convulsive  tremors  or  coma.  Death  has  followed 
from  this  form  in  three  days. 

3.  In  the  third  form  the  sj'mptoms  are  those  of  an  intoxication 
resembling  alcoholism  followed  by  paralysis  and  death.  Combe  in 
1827  reported  death  as  early  as  three  hours  after  eating  the  mussels, 
and  others  six  or  seven  hours,  and  still  others  after  longer  inter- 
vals. 

Various  theories  have  been  advanced  to  explain  the  cause  of  mussel- 
poisoning.  Brieger  has  isolated  a  toxin  from  mussels  which  he  calls 
mytilotoxin,  which  caused  a  fatal  case  of  poisoning.  Further  study 
is  needed  to  decide  the  question  of  the  toxin  principle  in  the  other 
forms. 

Shell-fish  taken  from  filthy  water  is  apt  to  be  poisonous.  At  Havre, 
France,  cases  of  poisoning  occurred  from  the  eating  of  oysters  taken 
from  near  the  outlet  of  a  drain  from  a  public  water-closet  (Pasquier). 
Various  rules  for  recognizing  poisonous  shell-fish  have  been  given, 
but  they  are  not,  as  a  rule,  reliable.  Shell-fish  that  is  fresh,  that 
has  been  taken  from  clean  water,  and  that  has  been  washed  with 
clean  water,  is  generally  safe.  Kept  at  a  summer  temperature, 
whether  cooked  or  not,  it  is  unfit  for  food. 

Poisoning  due  to  Fish  (Ichthyotoxismus). — Fish  may  be  poison- 
ous under  various  conditions : 

(1)  Some  are  always  poisonous.  (2)  Some  are  poisonous  during 
the  spawning  season.  (3)  Some  may  be  infected  with  bacterial  dis- 
eases which  may  cause  disease  in  man.  (4)  Like  other  nitrogenous 
foods,  fish  may  be  infected  with  bacteria  which  produce  toxins. 

Kobert,  according  to  Novy  and  Vaughan,  makes  the  following  classi- 
fication of  poisonous  fish: 

1.  Where  the  fish  are  supplied  with  poison  glands  connected  with 
barbed  fins,  with  which  they  wound  their  enemies,  like  the  poison 
of  snakes.     These  cause  prostration,  convulsions,  and  death  in  man. 

2.  The  genus  Tetrodon,  a  Japanese  fish  which  has  poisonous  ovaries, 
which  are  less  poisonous  in  winter,  when  the  ovaries  are  inactive. 
Kakke,  a  disease  of  Japan  and  other  Eastern  countries,  is  believed  to 
be  due  to  the  eating  of  certain  varieties  of  the  Scomhridae  family. 
(See  Beriberi.) 

3.  Certain  other  fish  whose  flesh  and  glands  are  harmless  may  be 
dangerous  on  account  of  the  decomposing  substances  or  corals,  etc.,  on 
which  they  feed. 

4.  Poisoning  due  to  ptoma'ins,  of  which  Anrep  has  isolated  two. 
These  are  due  to  the  fish  being  infected  with  saprophytic  bacteria. 
The  symptoms,  are  principally  due  to  involvement  of  the  gastro-in- 


DISEASES  CAUSED  BY  ERRORS  IN  DIET  217 

testinal  tract  and  nervous  system — nausea,  vomiting,  diarrhea,  pros- 
tration, rashes,  etc. 

In  Russia  and  Germany  there  are  certain  hsh  that,  if  eaten  raw,  may 
produce  disease,  but  that,  when  thoroughly  cooked,  are  harmless. 
The  cause  is  probably  found  in  a  bacterial  disease  of  the  fish. 

Meat-poisoning  (Kreotoxismus). — Many  forms  of  meat-poisoning 
have  been  described,  and  some  have  been  given  special  names.  Cer- 
tain diseases  the  result  of  direct  transmission  will  be  considered 
separately.  The  meat  of  animals  that  have  died  of  disease  of  any 
kind  is  unfit  for  food,  and  the  old  Mosaic  law,  "Ye  shall  not  eat 
anything  that  dieth  of  itself,"  ^  is  a  good  hygienic  rule.  The  Jewish 
laws  concerning  what  were  regarded  as  clean  and  unclean  meats  are 
set  forth  in  the  fourteenth  chapter  of  the  book  of  Deuteronomy. 

Poisoning  has  followed  the  ingestion  of  meats  of  various  kinds  in 
which  toxic  substances  had  formed.  Some  meats .  undergo  changes 
that  can  be  detected  by  ordinary  means,  while  in  still  others  putrefac- 
tive changes  are  not  apparent.  The  poisons  vary  in  nature,  and  in 
some  cases  toxins  and  bacteria  have  been  isolated.  Among  the  many 
foods  that  have  caused  meat-poisoning  may  be  mentioned  canned 
meats — pigs'  tongues,  potted  chicken,  and  the  like;  ham,  sausage, 
brawn,  veal  and  pork  pies,  ribs  of  beef,  goose-grease — in  fact,  almost 
every  kind  and  form  of  meat  foods. 

Sausage-poisoning,  known  as  botulismus  or  allantiasis,  has  been 
known  for  over  a  hundred  years.  It  is  becoming  less  frequent  as  the 
causes  that  give  rise  to  the  disease  are  becoming  better  known  to 
sausage-makers.  In  Baden,  Germany,  where  very  faulty  methods  of 
preparing  and  curing  sausage  were  in  vogue,  the  disease  was  formerly 
frequent.  Blood  that  had  become  decomposed  was  often  used,  and 
in  other  instances  the  sausage  was  imperfectly  cured,  the  outside 
being  smoked  and  rendered  harmless,  the  center  remaining  soft  and 
highly  poisonous.  For  this  reason  those  who  ate  the  outside  of  tlie 
sausage  exhibited  no  ill  effects,  while  those  who  partook,  of  the  center 
were  made  very  ill  and  many  died.  The  symptoms  vary  with  the 
kind  of  poison  that  has  developed  in  the  meat,  but  there  are  no  char- 
acteristic lesions  in  those  who  die. 

"Von  Faber,  in  1821,  observed  sixteen  persons  who  were  made  sick 
by  eating  fresh  unsmoked  sausage  made  from  the  flesh  of  a  pig  which 
had  suffered  from  an  abscess  on  its  neck.  Five  of  the  patients  died. 
The  symptoms  were  as  follows :  There  were  constriction  of  the  throat 
and  difficulty  in  swallowing,  retching,  vomiting,  colic-like  pains,  ver- 
tigo, hoarseness,  dimness  of  vision,  and  headache.  Later  on,  in  severe 
eases,  there  was  complete  exhaustion,  and,  finally,  paralysis.  The 
eyeballs  were  retracted,  the  pupils  were  sometimes  dilated  and  then 
contracted,  and  they  did  not  respond  to  light ;  there  was  paralysis  of 
the  upper  lids.     The  tonsils  were  swollen,  but  not  as  in  tonsillitis. 

1  Old  Testament:  Deuteronomy  xiv:  21. 


218  VARIOUS  FACTORS  IX  RELATION  TO  DIET 

Liquids  which  were  uot  irritating  could  be  carried  as  far  as  the 
esophagus,  when  they  were  rejected  from  the  mouth  and  nose  with 
coughing.  Solid  food  could  not  be  swallowed.  On  the  back  of  the 
tongue  and  in  the  pharynx  there  was  observed  a  puriform  exudate. 
Obstinate  constipation  existed  in  all,  while  the  sphincter  ani  was 
paralyzed.  Breathing  was  eas}^  but  all  had  a  croupous  cough.  The 
skin  was  dry  and  there  was  incontinence  of  urine.  There  was  no 
delirium,  and  the  mind  remained  clear  to  the  last. ' '  ^ 

Schiiz  cites  cases  of  poisoning  caused  by  eating  liver  sausage.  There 
were  loss  of  voice,  typhoid-like  stools,  marked  delirium,  and  mental 
disturbance  that  persisted  for  weeks  afterward.  The  onset  occurred 
in  from  eighteen  to  twenty-four  hours  after  eating  the  sausage,  and 
lasted  from  one  to  four  weeks.     There  were  no  deaths. 

Tripe  has  reported  over  60  cases  where  there  were  frequent  stools, 
weak  and  rapid  heart,  and  delirium.  The  pupils  were  usually  con- 
tracted but  reacted  to  light. 

Ballard  reported  490  deaths  due  to  pneumonia,  caused  in  most  of 
the  cases  by  eating  infected  bacon.  According  to  this  observer,  those 
who  had  the  disease  could  transmit  it  to  others  who  had  not  eaten  of 
the  meat,  a  fact  that  has  been  noted  in  many  other  instances.  After 
having  been  kept  several  months  the  bacon  lost  its  toxicity.  This 
epidemic  was  known  as  the  Middlesborough  pneumonia  epidemic. 

Another  interesting  epidemic  of  meat-poisoning  occurred  at  Mid- 
dleburg,  Holland.  Meat  from  a  cow  sick  with  puerperal  fever  was 
eaten  by  256  soldiers  and  36  citizens,  the  symptoms  consisting  of 
vomiting,  purging,  dizziness,  sleeplessness,  dilatation  of  the  pupils, 
and  in  some  cases  an  eczematous  eruption.     There  were  no  fatalities. 

The  present-day  opinion  regarding  many  of  the  disease  conditions 
following  eating  of  contaminated  foods  is  that  they  may  be  either 
caused  by  toxins  elaborated  by  bacteria,  or  the  toxins  in  the  bacteria 
themselves,  the  bacteria  in  question  being  pathogenic  for  some  of  the 
lower  auimajs,  but  not  capable  of  actually  producing  their  specific 
disease  in  man,  although  toxic  effects  may  manifest  themselves.  Ty- 
phoid, paratyphoid  A,  and  paratyphoid  B  are  diseases  of  man  and 
when  the  bacteria  are  ingested  into  a  susceptible  individual  the  dis- 
ease is  liable  to  follow.  Foods  may  be  contaminated,  however,  with 
other  organisms  that  produce  disease  in  animals.  There  is  a  large 
number  of  them,  among  which  may  be  mentioned  B.  suis  pestifer, 
which  produces  a  disease  in  pigs,  B.  pullorum,  producing  diarrheal 
disease  in  chickens,  B.  enteriditis,  affecting  cattle,  B.  abortus  equi,  in 
horses,  B.  typhi  muri,  in  mice,  and  a  number  of  others  which  need  not 
be  mentioned.  Food  products  contaminated  by  these  organisms  will 
not  cause  any  of  the  diseases  found  in  animals  in  man,  but  very  dis- 
tinct symptoms  as  noted  above  may  follow. 

1  Vaiighaii  and  Xovy,  Cellular  Toxins. 


DISEAtSES  CAltiED  ID    Eh'h'OU'S  /A    DIET  219 

OTHER  FORMS  OF  FOOD-POISONING. 

Mushroom-poisoning. — l'i)isuiiuus  fungi  are  often  mistaken  for 
edible  muslirooms,  and  lead  to  toxic  symptoms.  If  there  is  a  ring 
about  the  stalk  and  the  mushroom  peel  easily  and  has  pink  gills,  it 
is  said  to  be  non-poisonous.  This  rule  is  not  a  safe  one,  since  some  of 
the  most  dangerous  forms  of  fungi  answer  to  this  description.  The 
active  principle  in  these  poisonous  fungi  is  muscarin  or  some  allied 
alkaloid.  The  symptoms  produced  are  vomiting,  diarrhea,  cramps, 
and  great  prostration.  The  pupils  are  contracted,  and  in  children 
there  may  be  convulsions.  The  treatment  consists  in  emptying  the 
stomach  and  bowels  as  promptly  as  possible,  and  in  giving  atropin 
and  other  restoratives. 

Chestnuts. — Merrill  (Journ.  Am.  Med.  Assn.,  Jan.  24,  1914,  p. 
289 ) ,  reports  some  twenty  cases  of  a  toxemia  apparently  produced  by 
eating  chestnuts.  Most  of  the  patients  were  males  and  young.  The 
symptoms  were  variable,  but  included  gastro-intestinal  disturbance, 
great  prostration  and  a  slow  recovery.  It  is  not  determined  whether 
the  symptoms  are  caused  by  the  chestnuts  having  started  to  germinate 
or  whether  they  were  in  some  way  rendered  toxic  through  the  trees 
having  suffered  from  the  blight. 

Qrain=poisoning.^ — There  are  three  forms  of  grain-poisoning,  gen- 
erally described  as  ergotism,  pellagra,  and  lathyrism.  They  are  dis- 
eases seen  almost  exclusively  among  the  squalid  and  destitute,  the 
effects  being  due  to  insufficient  nourishment  combined  in  each  case 
with  the  specific  poison  from  the  grain.  Most  cases  and  epidemics 
have  occurred  among  the  poverty-stricken  European  peasants.  The 
well-to-do  and  properly  nourished  are  much  less  susceptible. 

Ergotism  (Sitotoxismus). — The  history  of  ergotism  is  most  interest- 
ing. It  is  very  probable  that  many  cases  of  "St.  Anthony's  fire," 
described  in  the  twelfth  century  and  later,  were  cases  of  grain-poison- 
ing. It  is  also  probable  that  syphilis  and  various  forms  of  ulcers  and 
gangrene  were  confounded  with  it  and  with  one  another.  It  is  not 
within  the  province  of  this  book  to  describe  the  horrible  epidemics  of 
the  middle  ages,  with  their  wake  of  mutilations  and  miser.y.  Within 
recent  years  epidemics  have  occurred  in  Russia. 

Thuillier  was  the  first  to  discover  that  the  cause  of  the  disease 
existed  in  spurred  rye.  He  also  pointed  out  that  the  rye  is  spurred 
in  the  damp,  cold  seasons,  and  that  the  degree  of  virulence  depends 
upon  the  amount  of  the  poison  taken.  He  proved  his  theories  by 
animal  experimentation.  Dodart,  in  1676,  ascertained  that  ergot  was 
most  active  when  fresh,  and  that  it  loses  in  virulence  as  it  ages.  It 
is  produced  by  a  microscopic  parasite,  known  as  Claviceps  purpurea, 
growing  on  the  rye.  The  disease  is  caused  by  eating  the  grain  on 
which  the  parasite  has  grown.  According  to  Kobert,  ergot  contains 
two  poisons,  sphacelinic  acid,  which  causes  gangrene,  and  cornutin, 


220  VARIOUS  FACTORS  IN  RELATION  TO  DIET 

which  provokes  the  anesthesia  and  convulsions.  The  susceptibility 
of  different  individuals  varies  greatly.  There  are  two  forms  of  the 
disease,  on,e  in  which  gangrene  is  the  prominent  feature,  and  a  second 
in  which  there  are  convulsions  and  anesthesia.  An  acute  and  a 
chronic  form  of  the  disease  occur.  In  the  gangrenous  form  there  are, 
at  tirst,  tingling,  anesthesia,  spasmodic  movements,  and  later  blood- 
stasis,  followed  by  gangrene  of  the  extremities.  In  the  convulsive 
form  there  are  prodromal  symptoms,  lasting  for  a  week  or  ten  days, 
consisting  of  headache,  weakness,  and  tingling  sensations.  Following 
these  there  are  cramps  in  the  muscles  and  convulsions.  The  spasms 
may  last  for  hours  or  days,  and  are  apt  to  recur.  Mental  disturb- 
ances and  symptoms  of  cord  involvement  may  supervene.  The  disease 
should  not  be  mistaken  for  erythromelalgia,  Raynaud's  disease,  or 
acrodynia,  whose  symptoms  it  simulates. 

According  to  Bottger,  ergot  may  be  detected  in  flour  by  mixing  a 
small  quantity  with  ether  and  adding  a  few  crystals  of  oxalic  acid. 
The  mixture  is  then  boiled  and  allowed  to  settle  and  clear.  If  ergot 
is  present,  a  red  tinge  will  be  imparted  to  the  fluid. 

Lathyrism  (Lupinosis). — This  is  a  milder  form  of  grain-poisoning, 
the  poisonous  agent  being  the  seed  of  Lathyrus  sativus  and  L.  cicera, 
commonly  known  as  the  chick-pea.  Poisoning  occurs  fro|m  the  meal 
ground  from  these  seeds,  which  has  been  used  to  adulterate  flour. 
The  disease  was  noted  as  early  as  the  seventeenth  century,  and  was 
studied  by  James  Irving  in  India.  As  the  result  of  the  failure  of 
the  wheat  crop  at  Allahabad  the  inhabitants  used  the  chick-pea  for 
food,  and  an  epidemic  of  lathyrism  followed.  The  disease  affects 
the  legs,  producing  a  stiffness  of  the  joints,  and  may  cause  a  spastic 
paraplegia. 

Potato-poisoning. — Potatoes  contain  small  amounts  of  an  alkaloid, 
solanin,  and  sprouting  potatoes  or  those  which  have  been  partially 
exposed  above  ground  may  contain  sufficient  to  produce  serioufe 
symptoms,  such  as  pain,  vomiting,  diarrhea,  jaundice,  and  great 
prostration. 

Chronic  Coffee  Intoxication. — Roch  gives  the  following  descrip- 
tion of  this  affection.  The  person  is  usually  thin,  prematurely 
wrinkled,  the  complexion  sallow,  and  there  is  a  tremor  of  the  hands, 
and  usually  mydriasis.  There  is  a  hesitating  or  brusque  or  uncertain 
manner  with  involuntary  movements  and  exaggerated  reflexes.  There 
is  a  tendency  to  neuralgia,  there  are  cardiovascular  symptoms  and 
usually  a  small  hard  rapid  pulse  with  an  increase  in  the  blood  pressure. 
There  are  also  digestive  disturbances.  This  picture  is  usually  not 
complete.     Tea  induces  similar  changes. 

Sugar. — It  seems  possible  that  unrefined  or  partially  refined  sugar 
products  may  contain  substances  that  are  injurious  as  suggested  by 
the  work  of  Blosser.     Kerley  and  others  have  pointed  out  the  fact  that 


DISEASES  CAUSED  BY  ERRORS  IN  DIET  221 

some  children  and  adults  are  susceptible  to  sugar  and  comparatively 
small  amounts  may  produce  asthma,  vomiting,  urticaria,  eczema,  etc. 

Phosphorus=poisoning. — It  has  been  reconnuended  that,  after  acute 
phosphorus-poisoning  all  fat  be  excluded  from  the  diet,  on  the  prin- 
ciple that  fat  will  dissolve  any  phosphorus  remaining  in  the  stomach 
and  so  hasten  its  absorption.  For  this  reason  the  articles  excluded 
should  be  not  only  the  butter  and  other  fats,  but  even  milk  and  the 
yolks  of  eggs.  The  diet  should  consist  chiefly  of  cereals,  gruels,  and 
the  like.  After  several  daj'S  the  ordinary  diet  may  gradually  be 
resumed. 

In  chronic  phosphorus-poisoning  IMagitot.  of  Paris,  recommends  an 
exclusive  milk  diet,  combined  with  the  inhalation  of  oxygen,  gentle 
exercise,  and  repeated  small  doses  of  turpentine.  If  suppuration 
has  occurred,  a  supporting  diet  of  the  most  nutritious  character, 
similar  to  that  used  for  other  suppurative  conditions,  should  be  pre- 
scribed. 

Actinomycosis. — This  disease  is  comparatively  rare  in  America. 
There  is  no  evidence  to  show  that  it  has  ever  been  transmitted  by 
articles  of  diet,  but  cases  are  recorded  where  the  infection  has  been 
traced  to  barley-sheaths,  to  grain  chewed  raw,  and  to  straw  being 
carried  in  the  mouth.  The  mammary  gland,  both  in  cows  and  in 
women,  may  be  infected,  but  so  far  no  case  has  been  traced  directly 
to  milk. 

Foot=and=mouth  Disease. — This  disease  may  be  transmitted  from 
infected  cattle  by  means  of  milk  or  butter  made  from  the  milk  of 
cows  suffering  from  the  disease,  as  well  as  by  direct  contact  with  the 
animals.  The  disease  was  studied  as  early  as  1834,  when  three  Ger- 
man veterinary  surgeons  drank  the  milk  from  infected  cows.  All 
developed  the  disease.  Infants  and  children  have  also  been  infected 
\y  drinking  contaminated  milk.  The  contagious  principle  is  de- 
stroyed by  heat,  but  the  flesh,  milk,  and  milk-products  of  animals 
with  foot-and-mouth  disease  should  not  be  used  for  food.  During 
epidemics  especial  care  should  be  taken  to  avoid  the  products  of  such 
animals,  and  in  case  of  doubt  the  milk  should  be  boiled  before  using. 

Hydatid  Disease. — Hydatid  cysts,  caused  by  the  eggs  of  Taenia 
echinococcvs,  may  also  be  classed  with  the  diseases  caused  by  diet. 
The  parasite  grows  in  the  small  intestine  of  dogs,  and  the  ova  are 
taken  into  the  alimentary  canal  of  man  by  drinking  water  containing 
them,  by  handling  dogs  and  carrying  the  infected  hands  to  the  mouth, 
and  by  eating  raw  green  vegetables.  The  disease  is  rare  in  America. 
In  the  medical  wards  of  the  Vienna  hospitals  a  routine  question  is, 
"Do  you  keep  dogs,  and  do  you  eat  green  salads?" 

FOOD  ALLERGY,      SENSITIZATION.  ANAPHYLAXIS,  IDIOSYNCRASY 

In  former  days  cases  in  which  food  caused  manifest  symptoms 
were  put  down  to  idiosyncrasy.     The  symptoms  generally  caused  are 


222  FOOD  ALLERGY 

gastro-intestinal,  urticarial  or  eczematous,  or  else  partake  of  the 
nature  of  haj^  fever  or  asthma.  These  conditions  need  much  further 
study,  but  there  is  no  doubt  that  many  of  them  are  due  to  sensitiza- 
tion to  food  proteins.  Just  how  far  these  changes  are  due  to  the 
unchanged  proteins  or  to  split  proteins  due  to  the  action  of  decompos- 
ing bacteria  or  to  the  bacteria  themselves  or  their  toxins  has  not 
been  worked  out.  This  hypersusceptibility  has  been  described  as  an 
unusual  or  exaggerated  supersensitiveness  of  the  organism  to  foreign 
substances.  This  is  seen  in  the  sensitiveness  of  the  tuberculous  to 
tuberculin  and  in  the  urticarias  produced  by  strawberries,  the  asthma 
due  to  e^g.  white  and  in  many  other  more  or  less  familiar  examples. 
These  symptoms  may  follow  the  inhalation  of  foreign  substances,  their 
ingestion,  or  may  be  due  to  bacterial  action.  Under  the  first  heading 
comes  the  hay  fever  and  asthma  due  to  the  pollens  of  plants,  the 
asthmas  due  to  the  inhalation  of  animal  products  such  as  that  which 
emanates  from  cats  or  horses,  probably  desquamated  epithelium. 
Under  the  second  heading  come  the  changes  which  follow  the  inges- 
tion of  grains,  nuts,  fruits,  mollusks,  meats,  milk,  eggs,  fish,  etc, 
fSee  also  Walker,  Journal  Medical  Kesearch,  1917,  xxxv,  xxxvi,  and 
Journal  of  Immunology,  1917.) 

The  presence  or  absence  of  this  sensitiveness  may  be  determined 
by  skin  tests  which  may  be  made  in  one  of  three  ways.  The  foreign 
material  may  be  introduced  on  a  scarification  as  suggested  by  von 
Pirquet,  by  using  a  dental  burr  or  a  small  jeweler's  screw  driver  or 
in  a  linear  scarification  or  by  injecting  intradermally.  The  linear 
cut  made  into  the  skin  but  not  deep  enough  to  draw  blood  is.  perhaps, 
the  best  as  being  freer  from  error  and  easier  to  read.  The  intrader- 
mal method  is  perhaps  more  sensitive,  but  more  difficult  of  interpre- 
tation. In  using  the  latter  the  injection  must  be  made  into  the  skin, 
not  through  it,  and  about  0.02  e.c.  of  solution  containing  the  protein 
used. 

The  tests  may  be  made  with  food  substances  as  by  appljnng  white 
of  egg  in  solution,  or  fat-free  milk,  or  salt-free  butter,  or  a  solution 
of  lactose,  or  a  gruel  of  the  grain  or  vegetable  to  be  tested.  It  has 
been  found,  however,  that  it  is  better  to  have  the  protein  as  free  as 
possible  from  extraneous  matter  and  to  this  end  extracts  of  the  various 
food  stuffs  have  been  made.  These  have  been  placed  on  the  market 
and  render  the  testing  of  an  individual  a  comparatively  simple  matter. 

The  test  is  best  made  on  the  flexor  surface  of  the  forearm  and  the 
place  should  be  watched  for  twenty  minutes.  The  reaction  usually 
appears  in  five  or  ten  minutes  and  consists  of  a  marked  swelling  and 
redness  like  an  urticarial  wheal.  It  is  always  well  to  make  control 
tests  as  some  individuals,  especially  those  with  exudative  diathesis, 
may  have  a  little  redness  and  swelling  about  a  simple  cut  or  abrasion. 
The  reaction  disappears  in  from  one  half  to  two  hours,  but  occasion- 
ally may  persist  for  twenty-four  or  more.     In  some  there  may  be 


SENSITIZATION  223 

itching  and  if  the  individual  is  extremely  sensitive  there  may  be 
more  or  less  marked  general  symptoms,  although  this  is  rare.  Oc- 
casionally the  reaction  may  be  delayed  and  sometimes  the  individual 
has  the  sensitisation  in  recurring  cycles,  so  that  in  negative  cases  the 
reaction  should  be  repeated  subsequently.  This  absence  of  reaction 
is  doubtless  due  to  the  fact  that  in  some  individuals  a  severe  reaction 
is  followed  by  a  period  of  variable  length  during  which  the  sensitive- 
ness is  absent. 

As  a  general  rule,  if  a  patient  reacts  to  one  protein  he  will  react  to 
a  number.  If  he  reacts  to  white  of  egg  he  will  be  found  to  react 
to  the  white  of  egg  of  various  fowls.  If  he  reacts  to  nuts  he  will 
usually  be  found  to  be  sensitive  to  the  various  nuts.  Talbot  reminds 
us  not  to  consider  the  peanut  in  this  connection,  as  it  is  a  legume.  If 
the  reaction  is  to  one  grain  it  will  usually  be  found  to  be  due  to  sev- 
eral. There  are  exceptions,  however,  and  the  whole  subject  needs 
much  more  careful  study.  Schloss  made  a  very  careful  study  of  a 
child  who  reacted  to  almonds,  oatmeal  and  egg,  but  not  to  other 
substances. 

Individuals  who  do  not  give  a  history  of  asthma  or  similar  affec- 
tions, or  eczema  or  urticaria  or  of  gastrointestinal  attacks  from  foods 
ordinarily  harmless  will  rarely  be  found  to  react,  whereas  a  large 
proportion  of  persons  with  such  a  history  will  react.  There  is  a  dis- 
tinct tendency  for  the  condition  to  run  in  families.  The  sensitiveness 
may  be  inherited  or  acquired.  Thus  infants  will  be  found  that  are 
sensitive  to  egg  white  when  it  has  never  been  given  them  before. 
The  intestinal  wall  of  the  new  born  has  been  found  to  be  pervious 
to  certain  proteins  and  these  substances  may  pass  directly  through  the 
intestinal  wall  into  -the  blood  and  may  be  demonstrated  in  the  blood 
and  in  the  urine.  This  may  explain  the  production  of  sensitization 
and  it  may  be  that  individuals  who  react  are  those  whose  intestinal 
tracts  have  been  at  one  time  or  are  pervious  to  certain  food  sub- 
stances. 

The  substances  causing  the  reaction  have  been  found  by  Wodehouse 
to  be  soluble  in  water  and  in  the  case  of  vegetables  they  are  not 
destroyed  by  heat,  while  in  the  case  of  fruits  they  are.  Thus  it  is  a 
well  known  fact  that  persons  in  whom  raw  strawberries  may  produce 
severe  reactions  are  not  affected  by  the  cooked  fruit. 

Wodehouse  extracts  the  active  substances  by  dissolving  them  out 
in  water.  No  one  method  will  do  for  all  substances,  but  in  a  general 
way  his  procedure  is  to  extract  the  substances  by  soaking  the  food 
in  water,  four  or  five  pounds  to  seven  or  eight  quarts  of  water,  adding 
thymol  as  a  preservative.  After  several  days  the  water  is  decanted 
and  filtered  and  then  evaporated  before  an  electric  fan  and  then  the 
gummy  residue  redissolved  in  a  little  water  precipitated  by  95  per 
cent,  alcohol,  washed  several  times  in  the  same  and  then  in  absolute 
alcohol,  then  in  ether,  and  finally  drying  over  a  sulphuric  acid  bath. 


224  FOOD  ALLERGY 

The  result  is  a  friable  powder  which,  if  it  is  not  freely  soluble  in 
water,  may  be  dissolved  by  using  0.1  per  cent,  of  potassium  hydroxid 
which  does  not  interfere  with  its  action. 

Strickler  and  Goldberg  (Journ.  Am.  Med.  Assn.,  Jan.  22,  1916,  p. 
249),  give  the  following  direction  for  preparing  the  materials  for 
testing : 

Preparation  of  the  Extracts. — Beef. — Ten  gm.  of  fresh  beef  were 
cut  up  finely  and  ground  with  sand  in  a  sterilized  mortar  until  the 
fibers  were  broken  down.  After  this  process  was  completed,  200  c.c. 
of  alkalinized  sodium  chlorid  containing  0.1  per  cent,  tricresol  were 
added,  and  the  entire  suspension  was  placed  in  a  sterile  flask  in  the 
incubator,  where  it  remained  for  thirty-six  hours.  It  was  taken  out 
and  the  material  placed  in  small  sterile  flasks  containing  sterile  beads 
and  placed  in  a  shaking  machine  for  two  hours ;  at  the  expiration  of 
this  time  the  flasks  were  again  transferred  to  the  incubator,  where 
they  remained  for  another  period  of  thirty-six  hours.  This  mixture 
was  then  filtered  through  sterilized  filter  paper  into  another  sterile 
flask,  and  the  amount  of  the  filtrate  measured.  In  the  case  of  beef 
it  was  55  c.c.  and  to  this  20  c.c.  of  absolute  alcohol  were  added.  The 
solution  was  placed  in  a  rather  flat  evaporating  dish  and  placed  on 
a  water  bath  at  80  C.  to  drive  off  the  fluid  and  leave  the  solid  residue. 
The  dried  material  was  scraped  off  the  surface  of  the  dish  and  placed 
in  a  desiccator,  to  make  absolutely  certain  that  all  the  water  had 
been  driven  off,  and  that  the  residue  was  perfectly  dry ;  5  gm.  were 
carefuUv  weighed  out  and  dissolved  in  100  c.c.  of  sterile  distilled 
water  containing  0.25  c.c.  of  tricresol.  (The  nitrogen  determination 
of  the  residue  shows  it  to  contain  4.72  per  cent,  nitrogen  or  29.5  per 
cent,  protein,  which  percentage  compared  very  favorably  with  the 
amount  of  protein  found  in  beef.)  The  entire  amount  of  beef  residue 
did  not  go  into  solution,  and  it  was  determined  to  find  out  accurately 
just  how  much  did  go  into  solution.  The  contents  were  filtered 
through  a  sterile  filter,  which  had  been  previously  weighed;  in  the 
case  of  beef  it  was  1.260  gm.,  but  with  the  beef  extract  it  weighed 
1.131  gm.,  showing  that  0.129  gm.  did  not  go  into  solution,  and  that, 
substracted  from  0.5  gm.,  left  0.371  gm.  in  solution. 

The  solution  was  cultured  in  glucose  agar  for  three  days,  and 
proved  to  be  sterile  and  was  placed  in  sterile  bottles  ready  for  use. 

Pork. — The  same  steps  were  followed.  Twenty  gm.  of  the  material 
were  used  with  200  c.c.  of  salt  solution  containing  0.5  per  cent,  phenol 
(carbolic  acid).  The  filtrate  was  154  c.c.  and  to  it  60  c.c.  of  absolute 
alcohol  were  added.  The  residue  with  filter  weighed  1.1  gm.,  while 
the  filter  weighed  1.015,  leaving  0.085  gm.  which  did  not.  go  into 
solution,  and  that  subtracted  from  0.5  gm.  showed  that  0.415  gm. 
were  dissolved  in  the  sterile.  The  solution  was  cultured  as  above  and 
proved  sterile. 


A 


PREPAKATIOX  OF  THE  EXTRACTS  225 

The  nitrogen  determination  of  the  residue  showed  8.82  per  cent, 
and  of  protein  23.9  per  cent. 

Mutton. — Twenty  gm.  of  this  material  were  employed  with  200 
c.c.  of  normal  salt  solution  plus  0.6  per  cent,  phenol.  The  amount  of 
filtrate  was  145  c.c.  to  which  60  c.c.  of  absolute  alcohol  were  added. 
Five-tenths  c.c.  of  dried  material  was  dissolved  in  100  c.c.  of  sterile 
distilled  water  plus  0.25  c.c.  of  tricresol.  The  solution  was  filtered 
and  the  weight  of  the  filter  was  1.19  gm.  and  the  weight  of  the  residue 
plus  the  filter  was  1.120.  The  amount  not  in  solution  was  0.03  gm. 
Subtracting  this  from  0.5  gm.  leaves  0.-47  gm.  in  solution.  The  solu- 
tion was  cultured  and  proved  sterile.  The  percentage  of  nitrogen 
mutton  residue  was  3.63  per  cent,  and  the  protein  percentage  was 
22.7. 

Fish. — Twenty  gm.  of  porgy  were  rubbed  up  with  sand  and  200 
c.c.  of  salt  solution  plus  0.5  per  cent,  phenol.  After  putting  this 
solution  through  the  same  procedure  as  the  material  described  above, 
it  was  found  that  the  filtrate  amounted  to  159  c.c.  and  to  this  60  c.c. 
of  absolute  alcohol  were  added.  Five-tenths  of  the  dried  residue  was 
dissolved  in  100  c.c.  of  sterile  distilled  water  plus  0.25  c.c.  of  tricresol, 
and  the  solution  filtered;  the  amount  of  the  residue  which  did  not 
dissolve  was  0.025  gm.  and  this  subtracted  from  0.5  gm.  showed 
0.475  gm.  in  solution.  The  solution  proved  sterile.  The  percentage 
of  nitrogen  was  3.23,  and  the  percentage  of  protein  was  20.2. 

Crab. — Twenty  gm.  of  crab  were  rubbed  up  with  sand,  and  200 
c.c.  of  the  normal  salt  phenol  solution  added.  After  shaking,  in- 
cubating and  filtering  it  was  found  that  the  filtrate  amounted  to 
122  c.c,  and  to  this  55  c.c.  of  absolute  alcohol  were  added.  Five- 
tenths  gm.  of  the  dried  residue  was  dissolved  in  100  c.c.  of  the 
tricresol  sterile  distilled  water  mixture,  and  it  was  found  that  it  all 
dissolved.  It  was  cultured  in  glucose  agar,  proved  sterile  and  was 
ready  for  use.  The  percentage  of  nitrogen  was  2.61,  and  of  protein 
16.3. 

Lobster. — The  same  procedure  and  the  same  quantities  which  were 
employed  in  preparing  crab  were  also  employed  in  preparing  lobster. 
The  dried  residue  was  all  dissolved.  The  percentage  of  nitrogen  was 
4.73,  and  of  protein  16.3. 

Wheat. — Eighteen  gm.  of  wheat  (flour)  were  rubbed  up  with  200 
c.c.  of  alkalinized  sodium  chlorid  (normal  sodium  chlorid,  500  c.c; 
normal  sodium  hydrate,  5  c.c ;  phenol,  0.5  c.c.  (0.1  per  cent.).  The 
solution  was  added  little  by  little  during  the  process  of  tritura- 
tion. The  solution  was  placed  in  a  flask  in  an  incubator  for  three 
days,  during  which  time  it  was  shaken  for  two  hours  in  a  shaking 
machine.  The  solution  was  filtered  and  289  cc  was  found  to  be  the 
amount  of  the  filtrate.  To  this  100  cc  of  absolute  alcohol  were 
added.  The  solution  was  placed  in  an  evaporating  dish  on  a  water 
15 


226  FOOD  ALLERGY 

bath.  The  dried  residue  was  removed  from  the  dish  and  0.5  gm. 
dissolved  in  100  c.c.  of  the  tricresol  sterile  distilled  water.  It  was 
filtered,  as  all  did  not  dissolve  and  the  amount  of  undissolved  residue 
was  0.15  gm. ;  that  subtracted  from  0.5  gm.  shows  that  0.35  gm.  were 
in  solution.  The  solution  proved  sterile  on  culture.  The  percentage 
of  nitrogen  was  1.77,  and  that  of  protein  11.1. 

Oats. — Nine  gm.  of  oatmeal  were  rubbed  up  with,  150  c.c.  of 
alkalinized  sodium  ehlorid  solution.  After  incubation,  shaking  and 
filtering  it  was  found  that  the  filtrate  amounted  to  2.2  c.c.  To  this, 
80  c.c.  of  absolute  alcohol  were  added.  Five-tenths  gm.  of  the  dried 
residue  was  dissolved  in  100  c.c.  of  tricresol  sterile  distilled  water 
and  filtered.  The  amount  which  did  not  dissolve  amounted  to  0.07 
gm.,  showing  that  0.43  gm.  was  in  solution.  The  nitrogen  percentage 
was  1.13,  and  the  protein  7.06. 

Rice. — Rice  powder  (rice  flour  of  Smith,  Kline  and  French)  was 
obtained;  of  this  product  10  gm.  were  rubbed  up  with  200  c.c.  of 
alkalinized  sodium  ehlorid  plus  tricresol.  After  incubating  and 
shaking  and  then  filtering  it  twice,  rice,  161  c.c,  plus  53  c.c.  alcohol, 
one-third  volume  of  absolute  alcohol,  were  added.  Precipitation  was 
slight.  The  preparation  was  placed  in  an  evaporating  dish;  the 
material  was  scraped  off  and  0.5  gm.  dissolved  in  100  c.c.  of  tricresol 
distilled  sterile  water.  Practically  all  dissolved.  The  percentage  of 
nitrogen  was  0.569,  and  that  of  protein  3.56. 

Barley. — Ten  gm.  of  Eobinson's  prepared  barley  was  ground  up 
with  200  c.c.  of  alkalinized  sodium  ehlorid  solution  plus  tricresol, 
incubated,  shaken  and  filtered.  The  amount  of  filtrate  was  158  c.c. 
and  to  this  52  c.c.  of  absolute  alcohol  were  added.  The  solution  was 
evaporated  on  a  water  bath,  and  of  the  dried  residue  0.5  gm.  was 
dissolved  in  100  c.c.  of  tricresol  sterile  distille^  water.  Practically 
all  went  into  solution.  The  solution  was  culturally  sterile.  The 
nitrogen  percentage  was  0.695  and  the  protein  4.34. 

Strawberries. — Good,  firm  strawberries  were  selected.  These  were 
ground  up  and  put  in  the  incubator  to  dry  out.  The  dried  material 
weighed  9  gm.  It  was  rubbed  up  with  200  c.c.  of  alakalinized  solution 
plus  tricresol.  It  was  incubated  and  shaken;  then  it  was  decided  to 
add  200  c.c.  of  the  alkalinized  solution  in  order  to  thin  the  mixture. 
It  was  filtered,  and  the  filtrate  amounted  to  289  c.c. ;  to  this  100  c.c. 
of  absolute  alcohol  were  added.  The  solution  was  evaporated  on  a 
water  bath  and  0.5  gm.  of  the  dried  residue  was  dissolved  in  100  c.c. 
of  tricresol  sterile  distilled  water.  It  did  not  go  into  solution,  0.06 
gm.  remaining  undissolved,  leaving  0.44  gm.  dissolved  in  the  100  c.c. 
of  solution.  Culturally  it  was  sterile.  The  percentage  of  nitrogen 
was  1.31,  and  of  protein  8.2. 

Tomatoes.^  Tomatoes  were  cut  into  small  slices  and  placed  in  the 
incubator  to  dry.  The  material  was  then  scraped  from  the  dish. 
The  material  collected  weighed  just  about  10  gm.     It  was  rubbed 


PREPARATIOX  OF  THE  EXTRACTS  227 

up  with  200  c.c.  of  tricresol  alkalinized  salt  solution,  incubated,  shaken 
and  filtered.  A  second  liltration  was  necessary.  The  filtrate 
amounted  to  140  c.c.  and  to  this  46  c.c.  of  absolute  alcohol  were  added. 
The  solution  was  placed  on  an  evaporating  dish  on  a  water  bath. 
Great  difficulty  was  experienced  in  drying  this  product ;  0.5  gm.  was 
dissolved  in  100  c.c.  of  tricresol  sterile  distilled  water  and  the  ma- 
terial went  into  solution  at  once.     Cultures  were  sterile. 

Cow-Casein. — One  gm.  of  Hammerstein 's  cow-casein  was  mixed  with 
100  c.c.  of  alkalinized  salt  solution  plus  tricresol,  placed  in  a  sterile 
flask,  incubated  and  shaken  for  two  hours.  The  solution  was  filtered, 
tested  for  albumin  and  found  positive.     Cultures  were  negative. 

Egg  White. — Five-tenths  gm.  of  egg  albumin  was  crushed  and 
powdered  in  a  sterile  mortar  and  dissolved  in  100  c.c.  of  normal  salt 
containing  0.25  per  cent,  tricresol.  The  solution  filtered  very  slowly. 
Some  of  the  egg  did  not  go  into  solution,  and  it  was  found  that 
0.465  gm.  was  dissolved.     The  solution  was  culturally  sterile. 

The  practical  application  is  to  test  patients  with  eczema  or  urticaria 
and  it  is  possible  that  some  of  the  other  skin  diseases  may  be  found 
more  or  less  dependent  on  food  sensitization ;  patients  with  the  history 
of  asthma  and  allied  conditions,  recurrent  bronchitis,  and  those  with 
gastrointestinal  symptoms.  If  the  offending  substance  or  substances 
can  be  determined  they  may  be  eliminated  from  the  diet  or  an  at- 
tempt made  to  desensitize  the  individual.  In  older  persons  very  ex- 
cellent results  may  be  obtained,  especially  in  eczema  and  asthma. 
In  infants  a  reduction  or  removal  of  the  protein  from  the  diet  may 
bring  about  a  great  temporary  improvement,  but  as  Blaekfan  has 
summed  it  up,  "it  is  impossible  to  feed  an  infant  for  a  long  time 
on  a  diet  that  contains  no  animal  protein  without  the  risk  of  seriously 
affecting  his  nutrition  and  because  there  is  a  strong  tendency  for  the 
eczema  to  return,  even  though  a  protein  poor  diet  produces  an  early 
improvement  and  even  though  the  protein  poor  diet  is  continued." 
Fortunately,  many  cases,  both  the  eczema  of  infancy  and  the  asthmas 
of  childhood,  tend  to  spontaneous  cure  with  time. 

The  desensitization  may  be  attempted  by  feeding  the  individual 
very  minute  amounts  of  the  offending  food  daily,  increasing  the 
amount  steadily  until  large  amounts  can  be  taken.  The  sensitive- 
ness generally  returns  unless  considerable  quantities  are  taken  daily. 

Desensitization  by  means  of  injecting  the  purified  proteins  has 
also  been  used.  This  procedure  is  perhaps  best  left  to  those  having 
experience,  as  incorrect  dosage  or  spacing  of  the  dosage  may  lead  to 
marked  reactions.  Extremely  small  amounts  should  be  used  at  first 
and  the  injections  made  not  over  four  days  apart,  as  longer  intervals 
instead  of  desensitizing  will  make  the  individual  more  sensitive  and 
alarming  results  follow. 


228  FOOD  ADULTERATION 

FOOD  ADULTERATION 

The  adulteration  of  food  is  a  subject  of  such  wide  scope  that  it  can 
not  be  entered  into  here  in  detail.^  The  subject  is  one  of  the  greatest 
importance  to  the  community  at  large;  and  where  legal  restrictions 
do  not  exist,  laws  should  be  enacted  which  will  insure  the  proper 
inspection  and  regulation  of  the  sale  of  all  food-stuffs.  The  sale  of 
injurious  articles  should  be  absolutely  prohibited,  and  adulterated 
but  non-injurious  commodities  should  be  properly  branded  so  that  the 
purchaser  may  not  be  compelled  to  pay  an  exorbitant  price  for  an 
inferior  article.  The  laws  should  apply  to  both  native  and  imported 
food-stuffs. 

In  the  United  States  the  law  enacted  July  1,  1903,  prohibits  the 
introduction  of —  ( a )  foods  containing  substances  deleterious  to  health ; 
(&)  those  misbranded;  and  (c)  foods  the  sale  of  which  is  prohibited 
in  the  country  from  which  they  are  shipped. 

Almost  all  the  States  have  enacted  food  laws  of  more  or  less  effi- 
ciency, but  the  laws  should  be  sufficiently  uniform  and  stringent  to 
prevent  the  sale  of  food-stuffs  deleterious  to  health,  and  to  prevent 
misbranding.  Although  under  the  present  law  imported  articles  are 
pure  and  properly  branded,  there  are  great  opportunities,  after  the 
articles  have  entered  the  country,  for  the  perpetration  of  fraud;  the 
same  is  true  of  native  food-stuffs. 

Food  adulteration  is  of  two  kinds :  that  which  is  injurious  and  that 
which  is  non-injurious.  The  latter  is  practised  where  there  are  no 
fixed  standards,  or,  where  such  do  exist,  in  debasements  from  these 
fixed  standards.     Adulterations  may  be  classified  as  follows : 

1.  Conventional — to  suit  the  taste  and  demands  of  the  public.  Such 
adulterations  are  usually  effected  by  means  of  coloring-matters,  many 
of  which  are  harmful,  and  by  bleaching  certain  products. 

2.  Accidental  or  incidental — arising  from  environment,  careless- 
ness, or  incompetency  on  the  part  of  the  producer,  manufacturer,  or 
his  agents.  This  usually  consists  in  an  admixture  of  some  foreign 
substance,  such  as  husks,  stems,  leaves,  etc. 

3.  Arbitrary — to  comply  with  or  take  advantage  of  certain  fixed 
arbitrary  standards. 

4.  Intentional — for  purposes  of  gain  and  competition. 
CoIoring=matters. — The  use  of  coloring-matter  in  food  is  a  moot 

point.  We  think  we  can  safely  assert  that  the  use  of  any  artificial 
coloring-matter  is  objectionable,  and  many  of  the  dyes  so  used  are 
harmful.     Fortunately,  the  people  are  being  educated  by  Wiley  and 

1  For  an  extended  study  of  this  subject  the  reader  is  referred  to  Blyth's  book 
on  Foods,  and  also  to  the  excellent  bulletins  of  the  Division  of  Chemistry  of  the 
United  States  Department  of  Agriculture.  The  bulletin  on  Food  Adulteration, 
known  as  No.  13,  of  which  some  ten  parts  have  already  been  issued,  can  be  found 
in  all  the  larger  libraries,  but,  unfortunately,  the  earlier  parts  are  out  of  print. 
It  is  to  be  hoped  that  this  bulletin  will  be  reprinted  at  an  early  date. 


ALCOHOLIC  BEVERAGES  229 

his  associates,  and  a  demand  for  pure  and  uneolored  foods  is  being- 
created. 

Alcoholic  beverages  are  frequently  adulterated.  Wood  or  methyl 
alcohol  is  sometimes  substituted  for  grain  or  ethyl  alcohol.  This  is 
especially  true  of  the  flavoring  extracts,  which  are  used  in  small  quan- 
tities. Wood  alcohol  is  an  exceedingly  dangerous  adulterant.  Blind- 
ness and  even  death  have  followed  its  use.  The  higher  they  stand  in 
the  series,  the  more  toxic  the  alcohols  become.  Hunt  has  shown  that 
a  larger  single  dose  of  methyl  alcohol  than  of  ethyl  alcohol  is  re- 
quired to  kill,  but  that  the  alcohols  differ  widely  as  regards  their 
effects  with  continued  use.  A  quantity  of  ethyl  alcohol  somewhat 
below  the  lethal  dose  may  be  taken  day  after  day  without  causing 
death,  whereas  repeated  large  doses  of  methyl  alcohol  may  speedily 
result  in  death,  the  reason  being  that  the  end-products  of  grain  alcohol 
are  acetic  acid  and  water,  whereas  the  end-products  of  wood  alcohol 
are  formic  acid  and  water. 

Adulterated  alcoholic  liquors  contain  fusel  oil,  tannin,  log-wood, 
water,  coloring-matter,  and  burnt  sugar.  Various  grades  of  cheap 
whisky  and  brandy  are  manufactured  by  unscrupulous  rectifiers  by 
mixing  newly  made  alcohol  with  coloring  and  flavoring  matters.  An 
imitation  of  gin  is  frequently  made  from  cheap  spirits,  turpentine, 
sugar,  and  water. 

The  Adulteration  of  Beer,  Wine,  etc. — Wine  and  heer  are  sophisti- 
cated by  the  addition  of  various  substances  usually  added  as  preserva- 
tives. Chief  among  these  is  salicylic  acid,  which  is  added  to  arrest 
the  action  of  ferments.  Its  use  is  forbidden  in  France  and  Germany, 
although  in  the  latter  country  it  may  be  added  to  beers  that  are  to 
be  exported. 

Gerard  found  that,  in  a  liter,  wine  contained  1.95,  1.60,  1.48,  1.41, 
1.35,  0.81,  and  in  one  case  as  much  as  3.5  grams  of  salicylic  acid; 
syrup  contained  in  the  same  quantity,  0.50-1.50  grams;  beer,  0.25- 
1.25  grams;  milk,  0.25-1.85  grams.  In  one  case  it  will  be  noted  that 
a  liter  of  wine  contained  a  full  twenty-four  hours'  dose  of  salicylic 
acid, 

Crampton  found  salicylic  acid  in  about  one-third  of  the  samples 
of  American  bottled  beer  which  he  examined.  He  did  not  find  any 
in  draft  beer.  Sulphurous  acid  is  one  of  the  oldest  of  preservatives. 
Its  use  is  forbidden  in  both  France  and  Germany.  Borax  is  fre- 
quently used,  and  is  also  forbidden  in  the  countries  mentioned. 
Sodium  bicarbonate  is  used  in  beer  to  correct  the  acidity  caused  by 
improper  brewing,  and  also  to  cause  an  increase  in  the  carbonic  acid 
content,  so  that  the  beer  will  have  a  better  "head." 

Wine  is  adulterated  by  adding  sugar,  gummy  substances,  coloring- 
matters,  and  salicylic  acid  and  mineral  acids  as  preservatives.  In 
France  wine  is  freriuently  plastered  by  the  addition  of  gypsum,  or 
calcium  sulphate.     As  Crampton  says:     "The  sulphuric  acid  of  the 


230  FOOD  ADULTERATION 

lime  salts  replaces  the  tartaric  acid  which  is  combined  with  potash, 
and  forms  an  acid  sulphate  of  potash,  while  the  tartaric  acid  separates 
out  as  a  tartrate  of  lime."  This  gives  the  wine  a  brighter  color, 
clears  it,  and  makes  it  keep  better. 

Adulterated  beer  may  contain  burnt  sugar,  licorice,  treacle,  quassia, 
coriander,  carawa;s'  seed,  Cayenne  pepper,  soda,  salicylic  acid,  salt, 
carbonic  acid  (artificially  introduced),  grains  other  than  barley, 
glycerin,  glucose,  water  (added  by  retailer),  tobacco,  and  Cocculus 
indicus. 

Cider  is  frequently  adulterated  by  the  addition  of  water  and 
preservatives,  and  is  also  manufactured  artificially. 

Many  of  the  liquid  malt  extracts  are  merely  beers,  and  most  of 
them  have  little  or  no  diastasic  action;  they  have  no  special  food- 
value,  nor  do  such  extracts  aid  digestion.  Some  are  adulterated  and 
harmful. 

Liqueurs  are  frequently  adulterated  and  imitated,  and  may  contain 
injurious  coloring-matter.  Maraschino  and  creme  de  menthe  cherries 
may  be  colored  with  anilin  dyes,  and  they  sometimes  contain  an 
astonishing  amount  of  coloring-matter. 

Tea. — Under  the  present  law  teas  imported  into  the  United  States 
are  practically  free  from  adulteration.  Many  inferior  teas  are  sold, 
however,  and  their  sale  is  not  restricted.  Tea  may  be  adulterated  by 
mixing  exhausted  or  foreign  leaves  with  it,  and  adding  coloring-matter 
and  astringents.  "Facing"  is  sometimes  practised,  and  consists  of 
treating  the  leaves  with  plumbago,  indigo,  or  Prussian  blue,  the  object 
being  to  make  an  inferior  tea  resemble  a  better  product.  The  small 
amount  of  the  adulterants  used  is  not  injurious,  and  the  adulteration 
is  easily  detected. 

Coffee. — Green  and  roasted  coffee  may  be  imitated.  An  inferior 
grade  of  coffee  is  frequently  branded  and  sold  as  a  better  article,  and 
roasted  coffee  may  be  adulterated  by  the  addition  of  too  much  glazing. 
Ground  coffee  is  frequently  adulterated,  and  may  contain  little  or  no 
coffee.     Chicory  is  th'e  commonest  adulterant. 

Cocoa  is  frequently  adulterated  by  adding  starch,  sugar,  clay, 
brick-dust,  coloring-matter,  and  flavoring  materials.  The  cocoa-butter 
may  be  extracted  and  tallow  or  other  fats  and  oils  substituted. 

Flour  is  adulterated  by  adding  other  grains  before  grinding  or  by 
mixing  other  flours  of  an  inferior  grade  or  from  a  different  grain. 
In  the  United  States  the  sale  of  "mixed"  flours  is  regulated  by  law. 
The  mixer  must  pay  a  special  tax,  and  the  product  must  be  correctly 
labelled.  Various  mineral  substances  have  been  found  in  European 
flours,  but  such  adulterants  are  seldom  used  in  the  United  States. 

Bread. — This  has  been  adulterated  by  the  use  of  inferior  flour,  and 
by  the  addition  of  other  substances.  Instances  have  been  reported  of 
the  use  of  sulphate  of  copper  and  of  ammonium,  and  alum  is  also  used. 
In  foreign  countries  soap  and  g3T)Sum  have  been  used,  and  stannous 


BITTER  231 

chlorid  has  been  added  to  bread  made  from  an  inferior  flour,  for 
the  purpose  of  making  it  resemble  that  made  from  a  better  quality. 

Butter. — This  may  be  adulterated  with  oleomargarin,  butterin 
water  ("stretched  butter"),  lard,  cotton-seed  oil,  beef  suet,  and  olive 
oil.  Butter  and  oleomargarin  have  about  the  same  composition,  and 
possess  about  equal  digestibility,  with  the  balance  slightly  in  favor  of 
butter.  Oleomargarin  is  not  injurious,  but  to  prevent  fraud  should 
be  correctly  labelled. 

Lard. — This  may  be  adulterated  with  stearin,  cotton-seed  oil,  and 
water.     The  adulterants  are  usually  harmless. 

Olive  oil. — This  is  frequently  adulterated  with  cotton-seed  oil,  etc. 
Foreign  oils  are  not  so  commonly  adulterated  as  formerly,  but 
foreign  labels  are  frequently  placed  on  impure  oils,  the  labelling 
being  done  in  the  United  States. 

Confectionery  is  sometimes  sophisticated  with  tartaric  acid,  glucose, 
starch,  soapstone,  and  other  substances.  Injurious  coloring-matters 
may  be  used. 

Spices. — These,  particularly  the  ground  spices,  are  frequently 
adulterated.  Black  pepper  has  been  extensively  adulterated  with  a 
large  variety  of  substances. 

Honey. — After  being  extracted,  honey  is  sometimes  adulterated 
with  glucose  or  cane-sugar  syrup.  This  is  not  practiced  to  as  great 
an  extent  as  commonly  supposed,  and  pure  extracted  honey  may  be 
bought  in  the  open  market.  Comb  honey  cannot  be  made  without  the 
aid  of  bees.  A  thin  sheet  of  beeswax,  in  which  there  are  hexagonal 
impressions  corresponding  to  the  bases  of  the  cells,  called  comb  founda- 
tion, is  used  very  extensively  to  bring  about  greater  uniformity  in  the 
size  of  the  cells,  and  also  to  lessen  the  labor  of  the  bee.  In  Europe 
it  is  said  that  cerasin  and  paraffin  are  used  for  this  purpose.  They 
cannot  be  successfully  employed  in  America,  however,  and  bee-keepers 
state  that  the  use  of  these  waxes  is  impossible.  Honey  may  contain 
poison.  Plugge  found  that  the  honey  from  Rhododendron  ponticum 
is  poisonous,  and  Xenophon,  in  his  Anabasis,  describes  attacks  of 
intoxication  due  to  eating  honey.  Although  death  seemed  near,  none 
of  his  soldiers  were  killed  by  it.  Strabo  and  Dioscorides  both  speak 
of  honey  as  producing  madness  or  melancholia.  In  Abyssinia  honey 
from  the  cusso  tree  is  used  as  an  anthelmintic.  The  honey  from 
gelsemium  is  also  poisonous.  In  Branchville,  S.  C,  twenty  persons 
were  made  ill  and  three  died  from  eating  honey  derived  from  this 
source.  In  New  Zealand  honey  from  the  "whauriki,"  a  cresslike 
plant,  causes  severe  symptoms  and  sometimes  death. 

Glycerin. — This  is  adulterated  with  glucose  and  water. 

Infant  Foods. — These  are  frequently  adulterated,  many  of  them 
being  merely  cereal  mixtures  for  which  an  exorbitant  price  is  charged. 

Baking-powder. — Starch  in  large  quantities  is  often  added  to 
baking-powder.     Alum  may  be  added  in  place  of  cream  of  tartar; 


232  FOOD  ADULTERATION 

but  if  the  powder  is  correctly  labelled,  and  the  addition  is  allowed 
by  the  state  law,  it  is  not  to  be  considered  an  adulterant.  Mallet 
regards  alum  baking-powders  as  injurious.     This  is  an  open  question. 

Canned  Vegetables  and  Meat. — These  frequently  contain  sub- 
stances deleterious  to  health.  Copper  and  zinc,  especially  the  former, 
may  be  used  to  color  peas.  Lead,  tin,  and  zinc  may  be  present  as  the 
result  of  unintentional  contamination.  Lead  may  gain  entrance  from 
the  solder,  which  is  frequently  used  in  large  quantities  and  allowed 
to  drop  into  the  can.  Lead-stoppered  bottles  are  also  sometimes  used, 
and  account  for  the  presence  of  lead  in  the  food.  Metallic  lead  is 
objectionable,  and  the  presence  of  lead  salts  is  highly  injurious. 
There  are  two  kinds  of  tin  plate  used  in  the  manufacture  of  cans — 
the  "bright,"  in  which  pure  tin  is  used,  and  the  "terne,"  in  which 
a  mixture  of  lead  and  tin  is  used.  This  latter  is  employed  for  roofing 
purposes,  although  it  is  sometimes  wrongly  used  for  cans.  Preserva- 
tives, such  as  sulphurous  acid,  salicylic  acid,  boric  acid,  and  others, 
are  frequently  added  to  canned  foods. 

Preservatives. — Various  chemicals  are  mixed  with  foods  to  preserve 
them.  In  many  countries  the  addition  of  such  preservatives  is  forbid- 
den by  law.  Sometimes  only  one  preservative  is  used,  but  often 
mixtures  of  two  or  more  are  added  in  combination.  Borax  and  boric 
acid  are  the  most  frequent  combination.  These  substances,  together 
with  sulphurous  acid,  sulphites  and  sulphates,  salicylic  acid,  benzoic 
acid,  and  formaldehyd,  are  most  frequently  employed.  A  large 
number  of  other  chemicals  are  used,  chiefly  to  evade  laws  that  forbid 
the  use  of  the  drugs  just  mentioned.  It  may  safely  be  stated  that 
the  addition  of  any  chemic  preservative  to  food  is  undesirable.  There 
are  differences  of  opinion  regarding  the  actual  effects  of  the  various 
preservatives  upon  the  human  body. 

Borax  and  boric  acid  as  preservatives  are  the  subject  of  numerous 
conflicting  opinions.  It  is  possible  that  some  of  the  favorable  opinions 
have  been  issued  by  those  who  draw  their  salaries  and  their  opinions 
from  the  same  source.  While  it  is  stated  by  many  that  the  use  of 
these  chemicals  is  not  injurious,  there  are  instances  on  record  where 
they  have  caused  severe  symptoms  and  even  death.  Boric  acid  and 
borax  may,  however,  find  their  proper  use  in  preserving  meats,  such 
as  hams,  for  exporting  purposes.  Meat  sprinkled  with  borax  or 
boric  acid  does  not  become  slimy,  as  it  does  without  it.  Before  the 
meat  is  used,  the  boric  acid  should  be  washed  off.  The  German  Gov- 
ernment has  expressly  forbidden  the  use  of  such  powders  on  meats 
imported  into  that  country.  This  restriction  may,  however,  have 
been  inspired  by  the  Agrarian  party,  and  not  by  consideration  for  the 
public  health. 

"Wiley  ^  concludes  as  the  result  of  his  experiments  that  boric  acid 

1  Results  of  Borax  Experiments.     Circular  No.  15,  Bureau  of  Chemistry,  United 
States  Department  of  Agriculture. 


SULPHUROUS  ACID  233 

and  borax  should  not  be  used  except  whore  preservation  is  a  necessity, 
and  where  it  has  been  shown  that  other  methods  of  preservation  can- 
not be  cmpk)yed.  Articles  containing  boric  acid  or  borax  should  be 
properly  branded  for  the  protection  of  the  young,  the  sick,  and  the 
debilitated.  Large  doses  (4  or  5  grams  a  day)  cause  loss  of  appetite 
and  of  ability  to  perform  work;  moderate  doses  (3  grams  a  day) 
cause  s^^mptoms,  but  the  subjects  are  able  to  continue  work  for  some 
time;  small  doses  {y^  to  2  grams)  may  be  taken  for  a  limited  time 
without  result,  but  unfavorable  symptoms  are  produced  in  some  cases, 
"It  appears,  therefore,  that  boric  acid  and  borax,  when  continuously 
administered  in  small  doses  for  a  long  period,  or  when  given  in  large 
doses  for  a  short  period,  create  disturbances  of  appetite,  of  digestion 
and  of  health. ' ' 

Harrington  ^  has  shown  that  boric  acid  may  be  the  direct  cause  of 
subacute  and  chronic  nephritis.  Food  preserved  with  these  drugs  is 
therefore  especially  injurious  to  individuals  suffering  with  Bright 's 
disease. 

Sulphite  and  bisulphate  of  sodium  are  used  for  preserving  all  sorts 
of  food,  and  especially  for  preserving  the  color  of  meats.  Their  use 
is  regarded  as  dangerous,  and  has  been  prohibited  in  Germany. 

Sulphurous  acid  is  frequently  used,  especially  for  preserving  wines. 
In  some  countries  a  certain  amount  of  sulphur  is  allowable  in  wine, 
but  the  amount  is  often  exceeded.  It  is  also  widely  used  in  preserving 
the  color  in  dried  fruits. 

Salicylic  acid  is  widely  used  as  a  preservative.  It  is  exceedingly 
powerful,  and  is  used  only  where  the  taste  of  the  article  is  not  im- 
paired, as  in  beer,  malt  extracts,  preserved  fruit  and  the  like.  In 
some  instances  the  amount  of  salicylic  acid  contained  in  food  to  be 
eaten  by  one  individual  in  twenty-four  hours  has  been  found  to 
equal  the  maximum  medicinal  dose  prescribed  for  the  same  length  of 
time.  It  is  undoubtedly  highly  objectionable,  and  its  use  should  be 
prohibited.  It  inhibits  digestion  and  irritates  the  kidneys;  food 
preserved  with  salicylic  acid  is  especially  injurious  in  cases  of 
Bright 's  disease. 

Formaldehyd  is  frequently  used  for  preserving  milk.  As  it  hardens 
meats,  it  is  not  usually  employed  as  a  meat  preservative.  In  general, 
it  may  be  stated  that  the  use  of  formaldehyd  as  a  preservative  is  un- 
desirable and  dangerous.  Attempts  have  recently  been  made  to  show 
that  in  milk  very  small  amounts,  1 :  100,000  and  less,  would  inhibit 
the  growth  of  bacteria,  and  at  the  same  time  not  be  prejudicial  to 
health,  even  to  that  of  infants.  According  to  Vaughn,  formaldehyd 
in  the  proportion  of  1 :  25,000,  or  1 :  50,000,  retards  the  growth  of  the 
lactic  acid  bacillus,  and  thus  delays  the  souring  of  milk,  while  it  has 
but  little  effect  on  the  multiplication  of  the  colon  and  typhoid  bacilli. 
It  removes  the  danger  signal  without  removing  the  danger.     Such 

1  American  Journal   of  Medical   Sciences,   September,   1904. 


234  FOOD  ADULTERATION 

use  of  formaldehyd  should  be  prohibited,  as  it  might  lead  to  the 
use  of  milk  which,  while  sweet,  might  still  be  ladeu  with  disease- 
producing  bacteria. 

Hydrogen  peroxid  is  used  to  a  slight  extent,  and  is  probably  the 
least  injurious  of  all  preservatives. 

Metallic  Poisons  and  Food. — Small  amounts  of  metals  or  their  salts 
may  find  their  way  into  food.  The  metallic  salts  are  highly  injurious, 
and  may  produce  either  acute  or  chronic  poisoning.  Many  cases  of 
lead-poisoning  are  traceable  to  contaminated  food. 

lead  has  been  considered  in  connection  with  canned  goods. 

Copper  may  be  added  intentionally  as  a  coloring-matter  or  it  may 
gain  entrance  from  the  use  of  copper  or  brass  kettles. 

Nickel  is  sometimes  used  to  color  green  peas,  and  may  be  found  in 
food  cooked  in  nickel  vessels.  In  the  latter  event  the  amount  found 
is  so  small  that  it  may  practically  be  disregarded. 

Zinc  is  sometimes  found  in  food,  especially  in  dried  apples.  It 
owes  its  presence  to  the  galvanized  iron  racks  upon  which  apples  are 
frequently  dried.  The  amount  present  is,  however,  so  small  as  to  be 
unimportant.  Zinc  may  also  enter  food  from  certain  kinds  of  solder, 
but  these  are  now  rarely  used. 

Arsenic  may  be  introduced  into  food  in  various  ways.  The  articles 
most  liable  to  contain  it  are  beer,  malt  extracts,  syrups,  and  foods 
containing  glucose  or  vinegar.  In  the  widespread  occurrence  of 
arsenic-poisoning,  in  Manchester,  over  6,000  persons  were  affected,  and 
over  100  died.  The  poisoning  was  caused  by  drinking  beer  which 
contained  arsenic  derived  from  impure  sulphuric  acid  used  in  the 
manufacture  of  brewing  sugar  or  glucose.  In  other  localities  the 
arsenic  has  been  found  to  be  contained  in  the  malt  which  had  been 
dried  in  kilns  heated  by  burning  arsenical  gas-coke. 

The  table  on  p.  235,  as  presented  by  Prof.  Sharpless,^  gives  the 
food  articles  likely  to  be  adulterated. 

SIHPLE  TESTS  rOH  DETECTION  OF  FEESERVATIVES. 

The  following  tests,  largely  adopted  from  Bigelow  and  Howard's 
article,  will  be  found  of  use  in  detecting  the  more  important  com- 
mercial preservatives,  with  the  exception  of  sulphites  and  fluorids. 
The  sulphites  are  used  in  meats  and  the  fluorids  in  fruit,  and  the 
methods  for  determining  their  presence  are  not  suited  for  household 
use. 

Salicylic  Acid. — This  is  very  commonly  used  in  all  kinds  of  foods, 
solids,  and  liquids,  especially  fruit  products.  It  is  best  detected  in 
solution,  and  solids  and  semisolids  should  be  macerated  in  water  and 
then  strained  through  a  white,  cotton  cloth.  Two  or  three  ounces  of 
the  fluid  to  be  tested  is  used,  adding  to  it  a  few  drops  of  sulphuric  acid 

1  From  Bulletin  No.  25,  Division  of  Chemistry,  United  States  Department  of 
Agriculture. 


SIMPLE  TESTS 


235 


Articles, 
Arrow-root. 


Brandy. 
Bread. 


Butter. 

Canned      vegeta- 
bles and  meat. 

Cheese. 

Candy   and  con- 
fectionery. 

Cofifee. 


Deleterious 
adulterants. 


Sulphate  of  alum. 


Copper. 

Salts     of     copper, 
lead. 


Salts  of  mercury 
in   the   rind. 

Poisonoiis  colors, 
artificial  es- 


Fraudulent 
adulterants. 
Other    starches    which    are    sub- 
stituted   in    whole   or    in    part 
for    the    genuine    article. 
Water,    burnt  sugar. 
Flours     other     than     wheat,     in- 
ferior  flour,   potatoes. 

Water,     other     fats,     excess     of 

salts,    starch. 
Excess    of    water. 


Oleomargarin. 
Grape-sugar. 


Chicory,  peas,  rye,  beans,  acorns, 
chebus-nuts,  almond  or  other 
nut-shells,  burnt  sugar,  low- 
grade  coffees. 


Accidental 
adulterants. 


Ashes  from  oven, 
grit  from  mill- 
stones. 

Curd. 

Meat  damaged 
in  the  process 
of  canning. 


Flour. 


Cocoa  and  choco- 

Oxid  of   iron   and 

Animal    fats,    starch,    flour,    and 

late. 

other     coloring- 
matters. 

sugar. 

Cayenne  pepper. 

Red  lead. 

Ground    rice    flour,    salt,     ship- 
bread,    Indian  meal. 

Oxid    of   iron. 

nour. 

Alum. 

Ground  rice. 

Grit    and    sand. 

Ginger. 

Turmeric,  Cayenne  pepper,  mus- 
tard,     inferior      varieties      of 
ginger. 

Gin. 

Alum     salt,    spirit 
of  turpentine. 

Water,  sugar. 

Honey. 

Glucose,    cane-sugar. 

Pollen      of     var- 
ious        plants 
and  insects. 

Isinglass. 

Gelatin. 

Lard. 

Caustic  lime, 
alum. 

Starch,  stearin,   salt.l 

Mustard. 

Chromate    of   lead. 

Yellow     lakes,     flour,     turmeric. 

sulphate  of  lime 

Cayenne   pepper. 

Milk. 

Water. 

Burnt    sugar,    annatto. 

Sand,  dirt. 

Meat. 

Infested  with  par- 
asites. 

Tainted. 

Horse-radish. 

Turnip. 

Fruit-jellies. 

Anilin  colors,  arti- 
ficial   essences. 

Gelatin,   apple-jelly. 

Oatmeal. 

Old  and  wormy. 

Pickles. 

Salts     of     copper, 
alum. 

Preserves. 

Anilin    colors. 

Ai)ples,    pumpkins,    molasses. 

Pepper. 

Flour,    ship-bread,    linseed    meal. 

Sand. 

Sago. 

Potato-starch. 

Rum. 

Cayenne      pepper, 
artificial         es- 
sences. 

Water. 

Burnt  sugar. 

Sugar. 

Salts    of    tin    and 

Rice-flour. 

Sand    and    dirt. 

lead,    gypsum. 

insects       dead 

Spices. 

Cloves. 

Cinnamon. 

Pimento. 

Tea. 


Vinegar. 


Wine. 


Sulphuric,  hydro- 
chloric, and  py- 
roligneous  acids. 

Anilin  colors, 

crude  brandy. 


Flour,   starches. 

Arrow-root. 

Spent  bark. 

Ship-bread. 

Foreign  leaves,  spent  tea,  plum- 
bago, gum,  indigo,  Prussian 
blue,  China  clay,  soapstone, 
gypsum. 


Water. 


and  alive. 


Ferrugin- 
ous  earth. 


Sulphate    of    po- 
tassium. 


(or  about  15  grains,  the  quarter  of  a  teaspoonful,  of  cream  of  tartar). 
Shake  thoroughly  and  filter.     To  the  clear  liquid  add  three  or  four 
tablespoonfuls  of  chloroform,  mix  by  a  rotary  motion,  but  do  not 
1  Tt  was  evidently  an  oversight  to  have  omitted  cotton-seed  oil  and  water. 


236  FOOD  ADULTERATION 

shake,  or  an  emulsion  will  be  formed,  which  is  difficult  to  break  up. 
Allow  the  chloroform  to  settle  and  remove  as  much  as  possible  by 
means  of  a  pipette  or  medicine-dropper.  This  is  placed  in  a  test-tube 
with  an  equal  amount  of  water  and  a  small  piece — a  little  larger  than 
a  pin  head — of  iron  alum.  Shake  well  and  allow  to  settle  and  if 
salicylic  acid  is  present  the  upper  layer  will  have  a  purple  color. 

Benzoic  Acid. — This  is  used  chiefly  in  fruit  products,  catsup,  etc. 
This  test  is  not  sufficiently  delicate  for  very  small  quantities,  such 
as  may  be  added  to  wine.  Proceed  as  above.  Evaporate  the  chloro- 
form by  placing  in  a  saucer  outside  of  a  closed  window.  In  cold 
weather  place  the  saucer  in  a  basin  of  rather  warm  water.  When 
the  chloroform  has  evaporated  the  characteristic  flat  crystals  of 
benzoic  acid  may  be  seen  in  the  saucer,  and.  on  warming,  the  charac- 
teristic irritating  odor  of  the  acid  can  be  detected. 

Borax  and  Boric  Acid. — Both  of  these  are  used  in  many  food 
products.  Macerate  solids  or  semisolids  as  above,  cool  the  liquid,  and 
filter  through  filter-paper. 

In  testing  butter,  place  a  heaping  teaspoonful  in  a  cup.  add  a 
couple  of  teaspoonfuls  of  hot  water,  stand  the  cup  in  hot  water  until 
the  butter  is  melted,  stir  well,  then  put  the  cup  in  cold  water  until  the 
butter  solidifies,  and  then  filter  the  liquid. 

For  milk,  use  an  ounce  of  milk  and  two  ounces  of  solution  of  a 
teaspoonful  of  alum  to  a  pint  of  water.     Shake  well  and  filter. 

Add  five  drops  of  hydrochloric  acid  to  a  teaspoonful  of  the  liquid, 
dip  a  piece  of  turmeric  paper  in  it,  and  dry  the  paper.  If  either 
borax  or  boric  acid  is  present,  the  paper  when  dry  becomes  a  sherry 
red.  A  drop  of  ammonia  turns  the  color  dark  green  or  greenish- 
black.  If  too  much  acid  has  been  used  the  color  may  first  be  brown, 
even  if  borax  or  boric  acid  is  present.  The  ammonia  turns  this  brown 
just  as  it  will  turn  turmeric  paper,  which  has  not  been  dipped  in  acid 
solutions. 

Saccharin. — Proceed  as  in  the  test  for  salicjdic  acid.  The  residue 
left  on  evaporating  the  chloroform  has  the  sweet  taste  of  saccharin. 
Sugar  is  not  soluble  in  chloroform,  so  will  not  be  present.  If  tannins 
are  present  the  astringent  taste  may  mask  the  taste  of  the  saccharin. 

Formaldehyd. — This  must  be  separated  by  distillation  in  foods 
other  than  milk.     For  milk  test,  see  chapter  on  milk. 

THE  DETERMINATION  OF  ARTIFICIAL  COLORS 

The  CoaNtar  Dyes. — If  the  substance  to  be  examined  is  not  a 
liquid,  dissolve  the  dj'e  bj'  macerating  it  in  water.  Filter,  take  two 
or  three  ounces  and  add  a  few  drops  of  hydrochloric  acid  and  a  few 
strands  of  white  woolen  yarn  or  pieces  of  white  woolen  cloth.  (Be- 
fore using,  the  wool  should  be  boiled  in  water  containing  a  little  soda, 
to  remove  any  fat  it  may  contain,  and  then  washed  in  water.)  The 
wool  which  has  been  boiled  is  washed  first  in  hot  and  then  in  cold 


DETERMINATIOX  OF  COLORS  237 

water,  and  the  water  pressed  out.  If  the  wool  is  not  discolored,  the 
substance  tested  may  be  regarded  free  from  artificial  colors.  If  the 
wool  is  colored  it  may  be  from  coal-tar  colors,  some  foreign  vegetable 
colors,  or,  if  a  fruit  is  being  examined,  the  natural  coloring-matter  of 
the  fruit.  Kinse  the  wool  in  hot  water  and  boil  three  minutes  in. 
two  ounces  of  water  to  which  two  drams  of  ammonia  have  been 
added.  Squeeze  out  the  excess  of  water.  Natural  fruit  color  is  re- 
tained, while  the  coal-tar  dyes  are  usually  dissolved  in  the  ammonia 
solution.  Add  hydrochloric  acid  to  this  fluid  until  the  odor  of  the 
ammonia  has  disappeared  and  the  liquid  has  a  sour  taste.  A  fresh 
piece  of  woolen  yarn  is  boiled  in  this,  and  if  it  is  colored,  the  sub- 
stance examined  has  been  artificially  colored.  Dull  faint  tints  must 
be  disregarded.  If  an  anilin  dye  (coal-tar)  has  been  used,  the  yarn 
will  usually  be  turned  purple  or  blue  by  ammonia. 

The  Detection  of  Copper. — This  is  often  used  in  coloring  canned 
peas,  beans,  etc.  Mash  the  substance  to  be  examined  and  add  a 
teaspoonful  of  the  pulp  to  three  teaspoonfuls  of  water  and  thirty 
drops  of  hydrochloric  acid.  Place  the  cup  in  which  this  has  been 
placed  in  a  water-bath  (saucepan  containing  water  will  do)  and  add  a 
bright  iron  wire  nail.  Boil  hard  twenty  minutes,  stirring  frequently 
with  a  splinter  of  wood  or  a  glass  rod.  If  copper  is  present  in  any 
appreciable  amount  the  nail  will  be  plated  with  copper. 

Turmeric— This  is  added  to  yellow  spices,  especially  mustard  and 
mace.  ^lix  one-half  teaspoonful  of  the  substance  to  be  examined  in 
a  white  china  dish  with  an  equal  amount  of  water  and  five  or  ten 
drops  of  ammonia.  If  turmeric  is  present,  a  brown  color  is  formed. 
If  an  insufficient  amount  of  the  dye  has  been  used  to  give  this  test, 
a  more  delicate  one  is  to  mix  a  teaspoonful  of  the  substance  to  be 
examined  with  an  ounce  of  alcohol  and  then  allow  it  to  settle  fifteen 
or  twenty  minutes.  About  one-half  ounce  of  the  upper  liquid  is 
placed  in  a  dish  with  five  drops  of  concentrated  solution  of  boric  acid 
or  borax,  10  drops  of  hydrochloric  acid,  and  the  solution  thoroughly 
mixed.  A  wedge-shaped  strip  of  filter-paper  two  or  three  inches 
long,  an  inch  wide  at  the  upper  end  and  one-quarter  inch  at  the  lower 
end,  is  then  suspended  so  that  the  lower  end  touches  the  solution. 
The  paper  should  not  touch  the  side  of  the  dish.  This  should  be 
allowed  to  stand  for  a  couple  of  hours,  and  if  turmeric  is  present, 
a  cherry-red  color  forms  on  the  filter-paper  near  the  upper  edge. 
This  red  color  is  turned  dark  green  or  almost  black  on  the  addition 
of  ammonia.  If  too  much  hydrochloric  acid  has  been  added,  a  brown- 
ish color  results. 

Caramel. — This  is  used  to  color  vinegar  and  other  fluids.  It  should 
be  borne  in  mind  that  caramel  occurs  naturally  in  malt  vinegar. 
Place  about  one  ounce  of  the  fluid  to  be  tested  in  two  test-tubes,  add 
a  teaspoonful  of  fuller's  earth  to  one  and  shake  vigorously  two  or 
three  minutes.     Filter  through  filter-paper.     The  first   part   of  the 


238  FOOD  ADULTERATION 

liquid  coming  through  the  paper  should  be  returned  to  be  filtered  a 
second  time.  If  the  filtered  liquid  on  comparison  with  the  untreated 
test-tube  is  markedly  lighter  in  color,  one  may  assume  that  the  color 
of  the  liquid  is  due  to  caramel,  which  is  largely  removed  by  the 
fuller's  earth.  This  test  reciuires  a  certain  amount  of  practical  ex- 
perience before  results  can  be  depended  upon. 

THE  EXAMINATION  OF  VARIOUS  FOODS 

Coffee. — The  difference  between  ground  coffee  and  that  which  has 
been  adulterated  can  often  be  told  by  the  naked  eye,  especially  if  not 
very  finely  ground.  Pure  coffee  has  a  uniform  appearance,  with  dull 
surfaces,  while  most  of  the  substitutes,  particularly  peas  and  beans, 
have  polished  surfaces.  Chicory  is  very  dark  and  gummy  looking 
and  the  particles  have  a  distinctly  astringent  taste.  On  placing 
ground  coffee  in  a  bottle  half  full  of  water,  shaking  it  and  allowing 
it  to  stand,  a  large  amount  of  the  coffee  will  float,  while  most  of  the 
substitutes  sink  at  once  to  the  bottom.  The  chicory  particles  will 
color  water,  and  as  they  sink  slowly  to  the  bottom  leave  a  little  dark 
train  behind  them.  Coffee  contains  no  starch,  while  all  of  the  sub- 
stances except  chicorj^  used  for  adulteration  contain  a  considerable 
amount.  All  ground  coffee  that  gives  a  starch  reaction  may  be  con- 
sidered as  adulterated. 

Flavoring  Extracts. — Vanilla  and  lemon  are  the  most  commonly 
used  and  most  adulterated.  They  are  frequently  made  with  the 
extract  of  the  tonka  bean,  which  can  be  determined  by  the  peculiar 
odor  by  any  one  familiar  with  the  two  products.  The  extract  made 
from  the  artificial  vanillin  lacks  the  resins.  Caramel  is  often  added 
to  color  it,  and  may  be  detected  by  shaking;  the  foam  of  pure  ex- 
tracts is  colorless,  and  if  caramel  is  present,  little  points  of  color 
will  be  seen  at  the  point  of  contact  with  the  bubbles.  The  fuller's 
earth  test,  given  above,  may  also  be  used.  To  examine  for  the  presence 
of  resins,  the  extract  should  be  evaporated,  and  when  it  reaches  one- 
third  its  volume  the  resins  become  insoluble  and  settle  to  the  bottom, 
while  artificial  extracts  remain  clear.  If  water  is  now  added,  the 
resin  will  separate  out  in  a  brown  precipitate.  A  few  drops  of 
hydrochloric  acid  should  be  added,  the  liquid  stirred  and  then  filtered ; 
the  resin  left  on  the  filter-paper  should  be  washed  with  water  and 
then  dissolved  in  a  little  alcohol,  and  to  one  part  of  this  add  a  few 
drops  of  hydrochloric  acid  and  to  another  a  small  particle  of  ferric 
alum.  The  resin  from  the  vanilla  bean  has  only  a  slight  change  of 
color,  while  with  most  other  resins  one  or  both  of  these  reagents  yield 
a  distinct  color  change. 

Lemon  extract  may  be  tested  by  placing  a  teaspoonful  of  the  oil 
in  a  test-tube  and  adding  two  or  three  teaspoonfuls  of  water.  With 
real  lemon  extract  the  fluid  first  becomes  turbid  and  later  the  oil 
of  lemon  separates  on  the  top  of  the  water.     If  it  remains  perfectly 


SPICES  239 

clear,  it  is  a  low-grade  product  and  contains  very  little  if  any  oil  of 
lemon. 

Spices. — The  detection  of  adulteration  in  spices,  for  the  most  part, 
requires  expert  knowledge  of  chemistry  and  microscopy.  Most  of 
the  substances  used  contain  starch,  but  so  do  most  of  the  common 
spices.  Cloves,  mustard,  and  cayenne  pepper  are  practically  free 
from  starch,  and  the  presence  of  it  may  be  taken  as  a  proof  of 
adulteration.  To  test  for  starch,  one-half  teaspoonful  of  the  sus- 
pected spice  should  be  stirred  into  one-half  cup  of  boiling  water  and 
boiled  for  several  minutes  and  then  cooled.  If  the  fluid  is  of  very 
dark  color  it  should  have  water  added  to  it,  and  to  this  a  single  drop 
of  iodine  is  added.  If  starch  is  present  it  gives  the  characteristic 
deep  blue  color,  and  if  very  much  is  present  it  turns  black.  If  no 
blue  color  appears,  the  iodine  should  be  added  drop  by  drop  until  it 
shows  in  the  solution. 

Vinegar. — The  simplest  test  is  the  odor.  If  it  is  not  apparent 
the  glass  should  be  rinsed  out  with  the  vinegar  and  allowed  to  stand 
for  some  hours,  when  the  odor  of  the  residue  will  be  quite  distinct ; 
cider  vinegar  having  the  fruit  odor  and  wine  vinegar  the  odor  of 
wine.  The  residue  may  also  be  obtained  by  evaporation.  If  the 
vinegar  has  been  colored,  the  caramel  can  be  tested  by  the  fuller's 
earth  test.  It  should  be  borne  in  mind  that  many  of  the  vinegars 
made  from  spirits  and  wood  have  apple  jelly  added  to  give  them  the 
characteristic  odor. 

The  Halphen  Reaction  for  Cottonseed  Oil. — Carbon  disulphide, 
containing  about  1  per  cent,  of  sulphur  in  solution,  is  mixed  with  an 
equal  volume  of  amyl  alcohol.  Equal  volumes  of  this  reagent  and 
of  the  oil  to  be  examined  are  mixed  and  heated  in  a  bath  of  boiling 
brine  for  fifteen  minutes.  In  the  presence  of  as  little  as  1  per  cent, 
of  cottonseed  oil  an  orange  or  red  color  is  produced  which  is  charac- 
teristic. Lard  and  lard  oil  from  animals  fed  on  cottonseed  meal  will 
sometimes  give  a  faint  reaction, 

DIET  AS  A  MEANS  OF  DIAGNOSIS 

Test-meals  are  given  to  determine  the  functional  disturbances  of 
the  stomach,  and  to  ascertain  whether  or  not  pathologic  conditions 
exist.  There  are  many  forms  of  test-meals  and  they  serve  various 
purposes. 

Test-meals  Employed  to  Stimulate  the  Gastric  Secretion  for  the 
Purpose  of  Determining  the  Secretory  Function  of  the  Stomach. — 
1,  The  Test-breakfast  of  Ewald  and  Boas. — This  consists  of  a  roll  or 
a  slice  of  wheat  bread  (35  to  70  gm.)  and  400  c.c,  of  water  or  tea 
■without  sugar  or  milk,  taken  in  the  morning  on  a  fasting  stomach. 
The  contents  of  the  stomach  are  removed  one  hour  afterward,  or  at 
varying  intervals  for  the  fractional  analysis  according  to  the  method 
of  Rehfuss. 


240  DIET  AS  A  MEANS  OF  DIAGNOSIS 

2.  The  test-dinner  of  Rieg-el  consists  of  400  c.c.  of  soup,  200  gm. 
of  beefsteak,  60  gm.  mashed  potato  and  a  roll,  (35  gm.),  and  a  glass 
of  water  (300  c.c.),  taken  at  noon.  The  stomach  is  emptied  of  its 
contents  in  from  three  to  four  hours. 

3.  Test-meal  of  Germain  See. — This  consists  of  60  to  80  gm.  of 
scraped  beef  and  100  to  150  gm.  of  wheat  bread.  The  contents  are 
removed  after  two  hours. 

4.  Test-meal  of  Klemperer. — Klemperer  gives  i/^  liter  of  milk  and 
70  gm.  of  wheat  bread  and  empties  the  stomach  two  hours  afterward. 

5.  The  Double  Test-meal  of  Salzer. — This  consists  of  40  gm.  of  beef 
scraped  and  boiled;  250  c.c.  of  milk;  50  gm.  of  boiled  rice,  and  1 
soft-boiled  egg.  This  is  followed  in  four  hours  by  an  Ewald  test- 
meal,  and  the  contents  of  the  stomach  are  withdrawn  one  hour  after. 

6.  The  Oatmeal  Test-breakfast  of  Boas. — This  breakfast  is  composed 
of  a  plateful  of  oatmeal  broth  prepared  by  boiling  down  to  i/o  liter  1 
liter  of  water  to  which  a  teaspoonful  of  oatmeal  and  a  pinch  of  salt 
have  previously  been  added.  This  test  has  for  its  object  the  deter- 
mination of  lactic  acid,  inasmuch  as  lactic  acid  is  present  in  all 
ordinary  breads  utilized  for  test-meals. 

On  account  of  its  simplicity,  the  Ewald-Boas  test-breakfast  is  most 
useful,  although  occasionally  a  Riegel  dinner  is  found  preferable; 
the  only  objection  to  the  latter  lies  in  the  fact  that  in  withdrawing 
the  stomach-contents  bits  of  meat  that  may  not  have  been  thoroughly 
digested  are  apt  to  obstruct  the  passage  of  the  contents  through  the 
tube.  In  examining  for  lactic  acid  the  Boas  oatmeal  test  is  preferred. 
(For  a  description  of  the  various  methods  of  examining  the  contents 
of  the  stomach  for  acid,  ferments,  etc.,  the  reader  is  referred  to  the 
text -books  on  diseases  of  the  stomach  and  on  clinical  diagnosis.) 

Dietetic  Tests  for  Determining  the  Motor  Power  of  the  Stom- 
ach.— 1.  Method  of  Leube. — This  test  consists  in  having  the  patient 
take  4Q0  c.c.  of  soup,  200  gm.  of  beefsteak,  50  gm.  of  bread,  and  200 
c.c.  of  water.  The  stomach  is  washed  out  at  the  end  of  six  hours;  if 
it  is  found  to  be  empty  at  this  time,  there  can  be  no  motor  impairment 
of  the  stomach. 

2.  Method  of  Boas. — If  the  stomach  be  washed  out  at  the  end  of 
two  hours  after  an  ordinary  Ewald-Boas  test-breakfast,  under  normal 
conditions  the  stomach  should  be  found  empty. 

3.  Test-supper  of  Boas. — This  supper  consists  of  cold  meat  with  bread 
and  butter  and  a  large  cup  of  tea.  If,  on  washing  out  the  stomach 
the  following  morning,  food  is  still  found  to  be  present,  a  dilatation 
of  the  stomach  exists. 

4.  The  addition  to  the  evening  meal  of  a  tablespoonful  of  currants, 
or  raisins  has  been  recommended  in  as  much  as  such  food  residues 
can  more  readily  be  recognized  in  the  wash  water  the  following  morn- 
ing. 

5.  The   Starch   Retention   Test   of   Hausmann. — A  test   supper   of 


STARCH  RETENTION  TEST  241 

a  small  plateful  of  boiled  rice  is  taken  at  night  and  the  fasting  stom- 
ach is  aspirated  the  following  morning.  The  contents  are  allowed  to 
sediment  and  the  supernatant  fluid  poured  off  and  tincture  of  iodine 
added  and  mixed  with  the  residue;  water  is  now  added  until  the 
mixture  is  transparent.  If  rice  granules  are  present,  they  will  appear 
as  blue  particles  in  the  fluid.  The  test  has  been  modified  by  some 
in  that  currants  or  raisins  are  added  to  the  rice  meal. 

Dietetic  Test  for  Determining  at  the  Same  Time  Disturbances 
of  both  the  Motor  and  the  Secretory  Functions  of  the  Stomach. — 
Method  of  Sahli. — In  this  test  substances  not  absorbed  b.y  the  stomach 
are  added  to  a  test-meal.  After  withdrawal  of  the  stomach-contents 
it  is  possible  to  determine  how  much  of  the  test-meal  has  passed  into 
the  intestine,  how  much  remains  in  the  stomach,  and  how  much  of 
the  withdrawn  meal  consists  of  gastric  secretion.  The  Sahli  test-meal 
consists  of  the  following:  25  gm.  of  ordinary  flour  and  15  gm.  of 
butter  are  placed  in  a  suitable  vessel  over  a  flame  and  allowed  to 
roast  until  brown.  To  this  are  slowly  added  350  c.c.  of  water,  and 
the  whole  stirred  constantly;  a  pinch  of  salt,  sufficient  for  seasoning, 
is  added,  and  the  mixture  is  allowed  to  boil  for  one  or  two  minutes. 
After  the  stomach  has  been  thoroughly  washed  out  the  patient  is 
given  300  c.c.  of  this  soup,  and  the  remaining  50  c.c.  are  retained  as 
a  control.  After  one  hour  the  stomach  contents  are  withdrawn  and 
the  quantity  is  noted.  Three  hundred  cubic  centimeters  of  water 
are  now  introduced  through  the  tube,  and  the  stomach  is  gently 
massaged ;  within  a  few  minutes  this  diluted  meal  is  withdrawn  and 
its  quantity  noted.^ 

Dietetic  Test  in  the  Diagnosis  of  Atypical  Cases  of  Ulcer  of  the 
Stomach. — In  cases  of  atypical  forms  of  ulcer  of  the  stomach  Leube 
advises  his  dietetic  treatment  (see  same)  as  an  aid  to  diagnosis.  If 
a  beneficial  result  follows  the  treatment,  the  presence  of  an  ulcer  is 
indicated. 

Dietetic  tests  are  often  of  value  as  a  means  of  diagnosis  and 
prognosis  in  diabetes  and  nephritis.  These  tests  are  described  in  the 
section  on  Diabetes  and  Nephritis. 

Schmidt  and  Strassburger  Test-Diet. — Breakfast :  500  c.c.  milk  (or, 
if  milk  be  badly  borne,  500  c.c.  of  cocoa,  made  of  400  grams  water, 
20  grams  cocoa,  10  grams  sugar,  and  100  grams  milk)  ;  in  addition, 
50  grams  of  zwieback.  Forenoon :  Half  liter  oatmeal  gruel,  made  of 
40  grams  oatmeal,  10  grams  butter,  200  grams  milk,  300  grams  water, 
one  egg  and  a  little  salt,  the  whole  to  be  passed  through  a  sieve. 
Mid-day:  125  grams  hashed  beef  (weighed  raw),  broiled  with  20 
grams  butter,  as  rare  Hamburg  steak;  250  grams  puree  of  potato 
(made  of  190  grams  mashed  potato,  100  grams  of  milk,  10  grams 
butter,  and  a  little  salt). 

1  For  the  method  of  examining  the  contents  see  Sahli,  Berlin,  klin.  Wochenschr., 
1902,  N"os.  16  and  17;  and  Aronson,  Medical  Record,  Dec.  5,  1903. 
16 


242  DIET  AS  A  MEANS  OF  DIAGNOSIS 

Afternoon :  Same  as  breakfast.  Evening :  Same  as  forenoon.  This 
diet  yields  2132  calories  and  contains  97  grams  of  protein,  11  grams 
of  fat,  and  191  grams  of  carbohydrates.  The  beginning  of  this  diet 
is  marked  by  giving  0.3  gram  of  carmine  in  a  konseal.  In  health 
this  diet  will  go  through  the  intestine  in  15  to  25  hours.  In  diarrhea, 
where  the  principal  trouble  is  in  the  colon,  in  10  to  15  hours,  and 
where  there  is  increased  peristalsis  of  the  entire  bowel,  in  3  to  5  hours. 
To  test  the  digestion  of  certain  articles  of  diet  twice  the  usual  amount 
should  be  given,  and  charcoal  may  be  used  to  mark  the  food  so  given. 
The  amount  of  mucus,  the  appearance,  the  reaction,  the  amount  of 
fermentation,  may  all  be  iloted.  This  method  of  studying  stools  is 
simple,  easilj^  carried  out,  and  of  great  practical  value. 

Schmidt's  Test-Diet. — On  arising  in  the  morning :  One-half  liter  of 
milk;  tea  or  cocoa  (if  possible,  with  milk),  together  with  one  roll  with 
butter,  and  one  soft-boiled  egg. 

Breakfast. — One  dish  of  oatmeal,  cooked  in  milk  and  strained  (salt 
or  sugar  permissible).  Under  certain  conditions  gruel  or  porridge 
may  also  be  given. 

At  Noon, — One-fourth  pound  of  finely-chopped  lean  beef  boiled 
rare,  with  butter  (the  interior  raw),  and,  with  it,  not  too  small  a 
portion  of  potato  broth    (well  strained). 

In  the  Afternoon. — Same  as  in  the  morning,  without  the  egg. 

In  the  Evening. — One-half  liter  of  milk  or  a  plate  of  soup  (as  in 
the  morning),  together  with  a  buttered  roll  and  one  or  two  eggs,  soft 
boiled  or  scrambled. 

The  test  diet  is  given  at  least  for  three  days,  until  a  stool  is  obtained 
coming  with  certainty  from  the  diet.  If  connective  tissue  appears 
in  the  stool,  it  is  an  indication  of  a  disturbance  of  gastric  digestion. 
If  muscle  appears  in  the  stools,  there  must  be  some  disturbance  of  the 
small  intestine.  If  both  muscle  and  connective  tissue  are  present,  a 
disturbance  of  both  stomach  and  intestine  is  at  hand. 

DIET  FOR  SINGERS  AND  SPEAKERS 

The  diet  exerts  considerable  influence  on  the  voice.  A  full  meal 
may  impair  the  respiration  to  such  an  extent  as  to  interfere  with 
singing  or  even  to  make  it  entirely  impossible.  The  congestion  of 
the  vocal  cords  which  may  follow  the  taking  of  food  or  drink  or  smok- 
ing often  has  an  injurious  effect  on  the  voice.  Irritating  articles  of 
food  and  drink  may  also  impair  the  voice,  and  should  always  be 
avoided  by  singers  and  speakers.  Singers  often  possess  curious 
idiosyncrasies,  certain  articles  of  food  impairing  the  voice  of  some 
while  improving  that  of  others.  W.  C.  Russell,  in  Representative 
Actors,  gives  an  interesting  list  of  articles  taken  by  prominent  actors 
before  going  on  the  stage.  He  states  that  Edmund  Kean,  Emery, 
and  Reeve  drank  cold  water  and  brandy;  John  Kemble  took  opium; 
Lewis,  mulled  wine  and  oysters ;  Macready  was  accustomed  to  eat  the 


DIET  FOR  SINGERS  AND  SPEAKERS  243 

lean  of  a  mutton  chop  previous  to  going  on  the  stage,  but  subsequently 
lived  almost  exclusively  on  a  vegetable  diet ;  Oxbury  drank  tea ; 
Henry  Russell  ate  a  boiled  egg;  W.  Smith  drank  coffee;  Braham 
drank  bottled  porter;  Miss  Catley  took  linseed  tea  and  Madeira;  G. 
F.  Cook  would  drink  anything;  Henderson  used  gum  arable  and 
sherry;  Incledon  drank  Madeira;  Mrs.  Jordan  ate  calves '-foot  jelly 
and  sherry;  C.  Kean  took  beef-tea;  Mrs.  Wood  sang  on  draught 
porter;  Harley  took  nothing  during  a  performance.  Malibran,  it  is 
said,  ate  a  lunch  in  his  dressing-room  half  an  hour  before  singing. 
This  consisted  of  a  cutlet  and  half  a  bottle  of  white  wine,  after  which 
he  smoked  a  cigarette  until  it  was  time  to  appear. 

As  a  rule,  nothing  should  be  eaten  before  singing  or  speaking.  The 
principal  meal  should  be  taken  two  or  three  hours  before,  and  it 
should  be  somewhat  lighter  than  usual.  INTany  singers  eat  but  little 
on  the  day  of  their  performance,  but  partake  of  a  good  meal  after- 
ward. A  food  much  used  by  singers  is  the  so-called  "'Jenny  Lind 
soup."  This  is  vey  bland  and  does  not  alter  the  voice.  It  is  made 
of  bouillon  and  sage,  to  which  are  added,  before  serving,  the  yolks 
of  two  eggs  beaten  up  in  a  half-pint  of  cream.  A  half-teaspoonful  of 
sugar  is  added,  and  it  is  flavored  with  spices.  Others  take  raw  eggs, 
egg  and  sherry,  or  albumin-water,  while  still  others  prefer  jellies  of 
the  gelatin  variety,  or  even  honey.  Orange-juice  has  its  advocates, 
and  the  chewing  of  dried  plums  has  been  recommended.  IMandl  sug- 
gests that  before  the  performance  the  singer  should  take  a  few  bites 
of  bread  or  chocolate  and  rinse  the  mouth  with  cold  water.  If  the 
song  is  lengthy,  cold  water  or  sugar  water  may  be  taken  during  the 
performance. 

In  the  interval  between  concerts  the  singer  should  live  on  a  general 
mixed  diet,  avoiding  irritating  foods.  Most  singers  have  a  tendency 
to  become  stout.  The  general  rules  for  dieting  the  obese  may  be  en- 
forced to  prevent  or  to  remedy  this. 

Alcohol,  in  the  form  of  the  stronger  beverages,  is  harmful  to  the 
voice  and  should  always  be  avoided.  Light  wines  and  beer,  except 
when  taken  to  excess,  are  not  generally  injurious.  They  are  best 
avoided,  however,  as  their  use  may  lead  to  the  formation  of  the  liquor 
habit. 

Smoking  is  injurious  to  the  voice.  According  to  Mackenzie,  how- 
ever, many  famous  singers  used  tobacco  freely  without  apparent  harm- 
ful effects. 

DIET  DURING  ATHLETIC  TRAINING 

The  course  of  diet  and  exercise  which  athletes,  both  amateur  and 
professional,  undergo  to  fit  them  physically  for  games,  contests,  or 
feats  of  endurance,  is  known  as  athletic  training.  The  necessity 
for  such  training  is  fully  recognized  by  all  athletes,  and  while 
opinions  differ  as  to  methods,  there  is  perfect  accord  in  the  ideal  that 
is  sought. 


244  DIET  DURING  ATHLETIC  TRAINING 

Professional  athletes  who  are  constantly  performing  feats  of 
strength,  skill,  or  endurance,  are,  for  the  most  part,  more  or  less 
constantly  in  training,  and  recognize  the  importance  of  keeping  in 
perfect  trim.  While  occasional  indulgences  may  not  be  harmful, 
continued  dissipation  is  always  disastrous  in  its  consequences.  This 
is  especially  true  where  finer  skill  and  judgment  are  required  and 
steady  nerves  are  a  necessity. 

The  ultimate  object  of  all  training  is  to  reduce  the  body-weight 
until  it  will  remain  constant  under  the  regular  routine  of  life  during 
the  training  period.  There  is  usually  a  loss  of  weight  for  the  first 
few  weeks,  varying  with  the  previous  condition  of  the  individual. 
In  about  three  weeks  the  weight  becomes  constant.  The  loss  of 
weight  is  accomplished  at  the  expense  of  the  fat  and  water  in  the 
tissues.  In  well-trained  men  the  muscles  are  hard  and  firm,  the  fat 
is  reduced  to  a  minimum,  the  skin  is  clear,  the  eyes  are  bright,  the 
expression  is  indicative  of  perfect  health,  the  body  is  active,  svelt, 
and  full  of  verve,  and  the  ' '  wind ' '  is  good.  In  the  undertrained  indi- 
vidual the  tissues  are  not  hardened  and  the  '"wind"  is  not  so  good. 
In  the  overtrained  there  is  a  curious  condition,  due  to  overexertion  or 
a  badly  chosen  dietary,  or  both,  and  the  individual  loses  weight  and 
energy,  and  is  in  every  way  unfitted  for  the  contest  for  which  he  was 
preparing. 

The  length  of  time  required  to  train  an  individual  varies  greatly, 
but  a  college  youth  of  the  average  athletic  type  can  usually  be  put 
in  good  shape  in  six  weeks.  The  transition  from  ordinary  life  to 
that  of  training  should  be  gradual.  This  is  true  both  of  diet  and  of 
exercise. 

The  diet-tables  of  various  trainers  difi'er  considerably.  As  a  gen- 
eral rule  it  may  be  said  that  the  diet  should  consist  of  wholesome  food, 
such  as  good  lean  beef  or  mutton,  best  given  underdone,  toast  or  stale 
bread,  and  potatoes  and  green  vegetables  of  all  kinds.  Among  the 
proscribed  articles  are  all  entrees,  puddings,  pastries,  sauces,  pickles, 
spices,  "appetizers,"  and  all  fancy  and  complex  dishes.  Twice- 
cooked  meat  should  be  avoided.  All  spirits  and  strong  alcoholic 
drinks,  as  well  as  tea,  coffee,  and  nerve  stimulants  of  any  kind,  should 
be  prohibited.  Some  trainers  allow  a  moderate  amount  of  light  wine 
or  beer,  while  others  forbid  their  use  entirely.  On  the  whole,  it  would 
seem  best  to  omit  them.     Tobacco  in  all  forms  is  forbidden. 

Water  is  usually  allowed  in  considerable  quantity— generally  as 
much  as  is  desired — early  in  the  training.  If  there  is  a  tendency  to 
obesity,  the  amount  is  somewhat  limited.  The  ({uantity  is  reduced 
gradually,  only  sufficient  being  allowed  to  allay  thirst;  it  should  be 
sipped  slowly.  The  importance  of  limiting  the  amount  of  water 
ingested  for  a  few  days  before  any  contest  is  recognized  by  all  pro- 
fessional athletes  and  trainers. 

Food  is  best  given  in  three  meals,  at  about  equal  intervals  of  time : 


DIET  DURING  ATHLETIC  TliAIMXG  245 

Breakfast  between  8  and  9 ;  dinner  between  1  and  2 ;  and  supper 
between  7  and  8  or  8  and  9. 

The  relation  of  sugar  to  training  is  of  special  interest,  and  opinions 
concerning  its  use  ditt'er.  Men  in  training  seem  to  crave  sugar,  and 
are  often  allowed  a  reasonable  amount  on  cereals,  or  in  tea  and  coffee 
when  the  latter  are  used,  but  it  is  generally  deemed  advisable  to 
forbid  its  use  in  pastries  and  cakes.  Further  study  is  needed  to 
decide  this  question.  In  this  connection  it  is  interesting  to  consider 
the  report  concerning  the  addition  of  sugar  to  the  diet  of  two  club 
crews  in  Holland  during  the  training  for  a  race.  Atwater  and 
Bryant  ^  cite  the  following  case : 

"Two  young  men  with  only  two  hours  a  day  for  practice,  at  the 
end  of  two  months  entered  for  the  race.  No  change  had  been  made 
from  their  usual  diet  except  that  they  ate  as  much  sugar  as  they 
wished,  sometimes  as  much  as  a  third  of  a  pound,  at  the  time  of 
their  dailj'  exercise.  One  of  them,  however,  did  not  make  this  addi- 
tion to  his  diet  until  the  third  week,  when  he  began  to  show  all  the 
signs  of  overtraining — loss  of  weight  and  a  heavy,  dull  feeling,  with 
no  desire  for  study.  On  the  third  day  after  beginning  the  use  of 
sugar  these  symptoms  disappeared.  At  the  time  of  the  race  both 
youths  were  victorious  over  their  antagonists,  who  did  not  believe 
in  the  use  of  sugar.     No  bad  effects  were  observed." 

The  accompanying  interesting  table  (p.  247)  is  taken  from  the 
report  -  mentioned. 

Thompson  ^  gives  the  following  report  of  the  Yale  crew,  on  the 
authority  of  Dr.  Hartwell,  formerly  a  captain  of  the  University  crew 
and  of  the  I^niversity  foot-ball  team : 

"The  training  covered  a  period  of  ten  and  one-half  weeks.  Break- 
fast, at  7.30  A.  M.,  consisted  of  fruits  (oranges,  tamarinds,  figs,  and 
grapes);  cereals  with  rich  milk  and  sugar,  etc.;  beefsteak,  usually 
rare;  chops,  stews,  hash,  with  once  or  twice  a  M^eek  some  salt  meat, 
as  bacon  or  ham,  usually  accompanied  hy  liver ;  stcM^ed,  browned,  or 
baked  potatoes ;  eggs  served  in  different  ways ;  oatmeal-water  and 
milk  as  beverage,  with  tea  on  special  occasions  for  some  particular 
individual.  Dinner  consisted  of  soups,  meats,  fish,  vegetables,  with 
a  simple  dessert,  such  as  rice,  bread,  or  tapioca  pudding,  some  fruit, 
and  the  same  beverages  as  at  breakfast  were  also  used.  The  meats 
included  roast  beef,  mutton,  or  chicken,  two  kinds  being  always 
served.  But  little  gravy  was  used.  Fish  was  served  twice  a  week. 
The  vegetables  included  potatoes,  mashed  or  boiled ;  tomatoes,  peas, 
beans,  and  corn.  Two  vegetables  besides  potatoes  were  usually 
served.  Supper  (8  to  8.15  p.m.)  consisted  of  cereals,  as  at  break- 
fast; chops,  stews,  or  cold  meat  from  dinner;  rarely  beefsteak;  po- 

1  Dietary  Studies  of  University  Boat  Crews. 

2  Bulletin  Xo.  75.  United  States  Department  of  Agriculture,  Experiment  Station. 

3  Practical  Dietetics,  p.  726. 


246  DIET  DURIXG  ATHLETIC  TRAINING 

tatoes,  stewed  or  baked;  and  eggs  about  three  times  a  week,  usually 
not  on  the  same  days  that  they  were  served  for  breakfast.  Sometimes 
ale  was  permitted  to  some  individual.  After  the  crews  were  in  final 
preparation  for  the  race  at  New  London  the  diet  varied  somewhat. 
Breakfast  and  dinner  remained  about  the  same,  but  a  light  luncheon 
of  cold  meat,  stewed  or  baked  potatoes,  milk  and  toast  was  served 
at  4.30  in  the  afternoon.  After  this  the  evening  exercise  was  engaged 
in  for  about  two  hours.  Forty-five  minutes  after  this  was  completed 
cold  oatmeal  or  other  cereal  with  milk  and  toast  was  served.  A  light 
supper  (9.30)  was  served  just  before  the  men  retired.  This  diet  was 
much  more  liberal  than  that  served  ten  years  before.  The  men  were 
allowed  as  much  food  as  they  desired." 

Atwater  and  Bryant  ^  give  the  following  account  of  the  diet  of  the 
Harvard  boat  crew  at  Cambridge,  in  1898,  in  the  description  of  the 
conditions  of  their  dietary  studies.  The  diet  was  simple,  and  con- 
sisted of  roast  and  broiled  beef  and  lamb,  fricasseed  chicken,  roast 
turkey,  and  broiled  fish.  Eggs,  raw,  poached,  or  boiled  in  the  shell, 
were  used  plentifully.  Large  amounts  of  milk  and  cream  were  also 
consumed.  Oatmeal,  hominy,  and  shredded  wheat  were  eaten  ex- 
tensively, and  corn  cakes  were  served  occasionally.  Bread  was  almost 
always  taken  in  the  form  of  dry  toast.  Potatoes  were  served  twice  a 
day,  either  baked  or  boiled  and  mashed  with  the  addition  of  a  little 
milk  and  butter;  occasionally  they  were  "creamed."  Boiled  rice, 
prepared  with  a  little  cream  and  sugar,  was  served  instead  of  po- 
tatoes at  some  meals.  Beets,  parsnips,  green  peas,  and  tomatoes  were 
used  to  furnish  a  variety  of  vegetables.  Macaroni  was  occasionally 
served.  For  dessert,  apple,  tapioca,  custard,  or  other  pudding  con- 
taining a  large  proportion  of  milk  and  eggs,  was  served.  The  mem- 
bers of  the  crew  were  allowed  beer  once  a  day.  Milk  was  obtained 
from  one  of  the  large  creameries  supplying  that  vicinity,  and  was  of 
unusually  good  quality,  containing  5.8  per  cent,  of  butter-fat.  A 
very  thick,  heavy  cream  was  also  used,  diluted  about  one-half  with 
milk.  This  mixture,  or  thin  cream,  contained  about  16  per  cent,  of 
butter-fat. 

The  beef  used  during  the  studies  was  entirely  from  the  loin.  The 
roasts  were  sometimes  from  the  fillet,  and  at  other  times  the  ordinary 
loin  roast  with  the  bone  was  used.  The  meat  was  sliced,  freed  from 
practically  all  the  clear  fat,  and  sent  to  the  table  in  a  large  platter, 
from  which  the  men  were  served  individually.  The  beef  was  served 
rare,  but  not  too  underdone;  some  of  the  other  club  tables  in  the 
same  house  served  much  rarer  meat.  The  beefsteak  was  freed  from 
bone  and  from  nearly  all  the  visible  fat  before  being  served. 

Lamb  chops  were  served  with  the  bone.  Lamb  and  mutton  roasts, 
which  were  all  taken  from  the  leg,  were  also  clear  meat,  trimmed  so 
as  to  be  practically  free  from  visible   fat.     The   turkey  used  was 

1  Loc.  cit. 


UXIVEKSITY  BOAT  CREWi^ 


247 


Summary  of  Results  of  Dietary  Studies  of  University  Boat  Orews  and 
Other  Dietary  Studies. 

(Nutrients  in  food  actually  eaten  per  man  per  day.) 


Oi 


.  si 


DIETARY  STUDIES  OF  UNIVEBSITY  BOAT  CREWS. 

Harvard  Univereity  crew  at  Cambridge  (No.  227) 
Harvard  Freshman  crew  at  Cambridge  (No.  228) 
Yale  University  crew  at  New  Haven  ( No.  229 )  . 
Harvard  University  crew  at  Grales  Ferry  (No.  230) 
Harvard  Freshman  crew  at  Gales  Ferry  (No.  231) 
Yale  Univei-sity  crew  at  Gales  Ferry  (No.  232^  . 
Captain  of  Hai"vard  Freshman  crew  (No.  233)  , 

Average 

SUMMARIZED  RESULTS  OF  OTHER  DIETARY  STUDIES. 

Football  team,  college  students,  Connecticut  ^  .  . 
Football  team,  college  students,  California  ^  .    .    . 

Professional  athlete,  Sandow^ 

Prize-fighter,  England  * 

Average  of  15  college  clubs* 

Average  of  14  mechanics'  families* 

Average  of  10  farmers'  families* 

Average  of  24  mechanics'  and  farmers'  families* 
Average  of  14  professional  men's  families    .    .    . 

DIETARY  STAJTDARDS.  ^ 

Man  with  modei-ate  muscular  work  (Voit)    . 
Man  with  modei-ate  muscular  work  (Playfair) 
Man  with  moderate  muscular  work  (Atwater) 
Man  with  hard  muscular  work  ^Voit)    .    . 
Man  with  hard  muscular  work  (Playfair) 
Man  with  hard  muscular  work  (Atwater) 
Man  with  severe  muscular  work  (Playfair) 
Man  with  severe  muscular  work  (Atwater) 


Gm. 

162 
153 
145 
160 
135 
171 
155 


155 


181 
270 
244 
278 
107 
103 
97 
100 
104 


118 
119 
125 
145 
156 
150 
185 
175 


Gm. 

175 

223 
170 
170 
152 
171 
181 


177 

292 
416 
151 
78 
148 
150 
130 
141 
125 


56 
51 

ioo 

71 
71 


Gm. 

449 
468 
375 
448 
416 
434 
487 


440 


557 
710 
502 
83 
459 
402 
467 
429 
423 


500 
531 

450 
568 

568 


Calor- 
ies. 

4130 
4620 
3705 
4075 
3675 
4070 
4315 


4085 

5740 
7885 
4460 
2205 
3690 
3465 
3515 
3480 
3325 


3055 
3140 
3500 
3370 
3630 
4500 
3750 
5700 


shipped  from  a  distance,  and  had  been  kept  in  cold  storage.  It  was 
baked  with  force-meat, — i.  e.,  "stufiflng"  or  "dressing," — although  but 
little  of  this  latter  was  served  to  the  crew.  Chicken  was  always 
fricasseed,  and  served  free  from  all  bones,  with  the  exception  of  those 
of  the  leg  and  wing. 

Broiled  fish,  usually  bluefish  or  Spanish  mackerel,  was  commonly 
served  for  breakfast,  as  were  also  eggs,  either  raw  or  poached.  No 
pastry  was  allowed,  and  the  puddings  were,  as  previously  stated,  com- 

1  Connecticut  (Storrs)   Sta.  Rpt.,  1891,  p.  128. 

2  Unpublished  material. 

3  Connecticut   (Storrs)   Sta.  Rpt.,  1896,  p.  158. 

4  Medical  Times  and  Gazette,  1865,  vol.  i.,  p.  459. 

5  United  States  Department  of  Agriculture  Yearlx)ok,  1898,  p.  450.  The  results 
are  summarized  from  Connecticut  (Storrs)  Sta.  Rpts.,  1891  to  1897,  and  the  bulle- 
tins of  the  United  States  Department  of  Agriculture. 

6  From  a  summary  in  United  States  Department  of  Agriculture,  Office  of  Experi- 
ment Stations,  Bulletin  No.  21.  pp.  206-213. 


248 


DIET  DURIiVG  ATHLETIC  TRAINING 


posed  largely  of  eggs  and  milk.  A  small  amount  of  coffee  jelly  was 
served,  and  at  one  meal  during  the  study  ice-cream  was  allowed. 
No  fresh  fruit,  with  the  exception  of  oranges  for  breakfast,  was 
served.  Stewed  prunes,  rhubarb,  or  apples  were  also  eaten,  prunes 
most  abundantly.  No  beverages  other  than  water,  milk,  and  beer 
were  allowed.  Breakfast  was  served  at  8,  lunch  at  1,  and  dinner  at 
6  o'clock,  although  one  or  the  other  of  the  crews  was  usually  late  at 
dinner.  Atwater  and  Bryant  ^  give  the  following  statistics  of  the 
Harvard  crew  at  Cambridge,  1898;  the  positions  shown  in  the  table 
are  those  occupied  by  the  different  men  at  the  time  of  the  race : 


May  23. 

May  24. 

May  25. 

May  26. 

Position. 

Age. 

Before 

After 

Before 

After 

Before 

After 

Before 

After 

rowing. 

rowing. 

rowing. 

rowing. 

rowing, 

rowing. 

rowing. 

rowing. 

Yrs. 

Pounds. 

Pounds. 

Pounds. 

Pounds. 

Pounds. 

Pounds. 

Pounds. 

Pounds. 

2 

20 

155 

158 

154| 

1561 

154J 

155f 

154J 

3 

21 

163 

162i 

160^ 

162i 

161^ 

163i 

16H 

4 

20 

165 

166 

163  J 

165 

163 

164i 

162# 

5 

19 

leoi 

161 

158i 

161 

159i 

161i 

159J 

6 

22 

173i 

174 

172 

174 

172 

173i 

170 

7 

19 

161i 

160 

157 

159 

156J 

160i 

157J 
146| 

Stroke    .... 

26 

147 

147^ 

145i 

148 

145| 

149 

Substitute    .  . 

171 

171 

168 

171 

1684 

170 

168 

Average    .  .   . 

162 

162i 

160 

162| 

160i 

162i 

160 

Average  loss   . 

2i 

2 

2i 

Remarks.— On  Mav  23  weight  not  taken  after  rowing.     May  24,  medium  work. 
May  25,  hard  work— eight  minutes  of  very  hard  work.    May  26,  light  work. 

' '  The  loss  of  weight  during  the  period  of  exercise  is  due  principally 
to  water  of  perspiration  and  the  water  and  carbon  dioxid  excreted 
in  the  breath." 

It  is  interesting,  in  this  connection,  to  compare  the  diet  of  the 
English  boat  crews,  as  given  by  Yeo.^  Maclaren  gives  the  following 
schemes  of  training  as  carried  out  at  Oxford  and  Cambridge : 


A  DAY'S  TRAINING  FOR  THE  SUMMER  RACES. 


OXFOBD 

7  A.M.:   Rise.     A  short  walk  or  run. 

8.30  A.  M. :  Breakfast  of  underdone 
meat,  crust  of  bread  or  dry  toast, 
tea  (as  little  as  possible). 

2  P.M.:  Dinner:  meat  (as  at  break- 
fast ) ,  bread,  no  vegetables  ( not 
strictly  adhered  to ) ,  1  pint  of  beer. 

.5  or  5.30  p.  M. :  Rowing  exercise. 

8.30  or  9  P.M.:   Supper:   cold  meat  or 

bread,  sometimes  jelly  or  watercress, 

1  pint  of  beer. 
10  P.  M. :  Retire  to  bed. 


Cambridge. 

A  run  of  200  yards  as  fast  as  possible. 

Underdone  meat,  dry  toast,  tea  2  cups 
(later  only  li),  water-cress  (occa- 
sionally ) . 

Meat  ( as  at  breakfast ) ,  bread,  pota- 
toes, and  greens,  1  pint  of  beer.  Des- 
sert: oranges,  biscuit,  or  figs,  2 
glasses  of  wine. 

Rowing  exercise. 

Cold  meat,  bread,  lettuce  or  watercress, 
1  pint  of  beer. 


1  Loc.  cit. 

2  Food  in  Health  and  Disease,  p.  281. 


A  DAY'S  TRAINING  249 

A  DAY'S  TRAINING  FOR  THE  WINTER  RACE. 
Oxford  Cambridge. 

7.30  A.  M.:   Rise.     A  short  walk  or  run.  7  .\.  M.:  Exercise  as  for  siunmer  races. 

!)  A.M.:   Breakfast,  as  in  summer.  SMO  a.m.:  Breakfast  as  in  summer. 

1  p.  M.:  Luncheon:  bread  or  a  sandwich  A  little  cold  meat,  bread,  and  i  pint  of 
and  k  pint  of  beer.  beer,   or  biscuit  and  glass  of  sherry 

2  p.m.:  Rowing  exercise.  (sometimes     yolk     of     egg     in     the 

sherry ) . 
Rowing  exercise. 
5   p.  M. :    Dinner :    meat  as   in   summer,      5  to  6  P.  M. :  Dinner,  as  in  summer, 
bread,  same  rule  as  in  summer  as  to 
vegetables,  rice  pudding  or  jelly,  and 
i  pint  of  beer. 
10  p.  M. :   Retire  to  bed. 
Water     strictly     forbidden.     As     little 
liquid  to  be  drunk  as  possible. 

In  summing  up  the  results  of  their  observations  Atwater  and 
Bryant  state  that,  in  a  "general  war,  the  difference  between  the  food 
of  the  athletes  and  that  of  other  people  represents  a  difference  in 
actual  physical  need  even  if  neither  is  an  accurate  measure  of  that 
need."  One  of  the  chief  differences  lies  in  the  fact  that  the  food  of 
athletes  is  productive  of  a  larger  amount  of  energy  than  that  con- 
sumed by  ordinary  working-people  or  college  men.  The  daily  excess 
over  the  ordinary  diet  was  about  400  calories,  or  about  10  per  cent. 
The  amount  of  protein  consumed  was  45  per  cent,  larger.  ' '  In  other 
words,  the  difference  in  protein  was  four  and  one-half  times  as  great 
as  the  difference  in  fuel-value,  and  the  excess  in  protein  would  account 
for  a  considerable  part  of  the  excess  of  energy  of  the  diet  of  the 
athletes  as  compared  with  men  in  ordinary  occupation." 

Atwater  and  Bryant  ^  close  the  account  of  their  experiments  with 
the  following  interesting  observations : 

"In  this  connection  it  is  interesting  to  observe  that  many  phy- 
siologists are  coming  to  entertain  the  view  that  the  amount  of  metabol- 
ism in  the  body  is  regulated  not  simply  by  the  muscular  work,  but 
also  by  the  nervous  effort  required  in  the  performance  of  this  work. 
The  especially  large  proportion  of  protein  observed  in  the  dietary 
studies  of  the  university  boat  crews,  of  foot-ball  teams,  of  the  pro- 
fessional athlete,  and  of  the  pugilist,  as  compared  with  the  dietary 
studies  of  college  men  with  ordinary  exercise,  and  with  ordinary  fam- 
ilies of  workingmen  and  professional  men,  accord  well  with  a  view  not 
uncommon  of  late  among  physiologists.  According  to  this  view,  men 
who  perform  continued  muscular  labor,  even  if  it  is  active  enough  to 
make  the  total  amount  large,  do  not  require  especially  large  amounts 
of  protein  in  their  food  so  long  as  they  undergo  no  especial  mental 
strain  or  muscular  fatigue,  the  principal  requirements  being  an 
abundant  supply  of  easily  digested  food-material.  On  the  contrary, 
when  a  man  or  animal  must  perform  intense  muscular  work  for  a 
.short  period  of  time,  and  is,  therefore,  under  more  or  less  nervous  as 

1  Loo.  cit. 


250  DIET  DUBIXG  ATHLETIC  TRAINING 

well  as  muscular  strain,  a  considerably  larger  supply  of  protein  seems 
to  be  required  than  under  normal  conditions  of  slow,  long-continued 
work.  In  other  words,  if  a  large  amount  of  work  must  be  done  in  a 
short  time  a  considerable  excess  of  protein  is  required  in  the  food. 
This  view,  which  has  been  especially  advocated  by  Zuntz,^  seems  to 
be  favored  by  the  results  of  dietary  studies  above  discussed. 

"Recent  experiments  made  by  Dunlop,  Paton,  Stockman,  and  Mac- 
cadam  ^  have  to  do  with  the  amount  of  protein  required  when  severe 
muscular  work  is  performed.  The  results  are  discussed  with  especial 
reference  to  training,  and  are  believed  to  "show  the  importance  of 
two  points  long  known  to  athletes  and  others  doing  excessive  muscular 
work.  The  one  is  the  importance  of  proper  training,  for  by  it  an 
abstraction  of  protein  matter  from  tissues  other  than  muscle  can  be 
avoided ;  the  other  is  the  importance  of  there  being  a  sufficiency  of 
protein  in  the  diet  to  compensate  for  the  loss  which  occurs.  An 
abundance  of  protein  in  the  diet  of  an  athlete  has  other  functions  to 
fulfil  besides  this.  It  is  required  during  training  for  building  up 
the  energy-liberating  mechanism — the  protoplasm  of  muscle;  and  it 
is  also  required  after  work  to  repair  that  mechanism.  The  benefits  of 
training  are  well  known  in  other  ways,  such  as  preparing  the  heart 
for  suddenly  increased  duty  and  limiting  the  after  fatigue  efi'ects. 

"The  power  of  the  body  to  perform  the  maximum  of  muscular 
work  within  a  comparatively  short  time  and  with  a  minimum  amount 
of  fatigue  is  secured  by  means  of  training.  Of  course,  skill  in  applica- 
tion of  muscular  strength  is  as  essential  as  is  the  amount  of  power 
exerted.  The  skill  is  sought  by  exercise  and  practice.  The  object 
of  regulating  the  diet  in  training  is  not  only  to  furnish  the  material 
to  supply  the  power,  but  also  to  put  the  machine  in  the  best  condition 
for  developing  as  well  as  applying  the  power.  In  other  words,  the 
man  is  to  be  subjected  for  a  short  time  to  intense  muscular  strain  and 
considerable  nervous  efi^ort.  This  he  is  to  bear  with  a  maximum  of 
result  and  the  minimum  of  fatigue.  For  this  he  needs  practical 
training,  on  the  one  hand,  and  proper  diet,  on  the  other.  If  the 
views  above  presented  are  correct,  the  diet  for  men  from  whom 
intense  muscular  effort  is  required  for  short  periods  should  supply 
liberal  amounts  of  energy  and  especially  large  amounts  of  protein." 

1  United  States  Department  of  Agriculture,  Experiment  Station  Record,  vol. 
vii.,  pp.  5.38-.550. 

2  Jour.  Physiol.,  1897,  vol.  xxii.,  p.  69. 


INFANT  FEEDING 

The  subject  of  infant  feeding,  during  both  health  and  disease,  is 
one  of  extreme  importance,  and  one  on  which  success  in  pediatric 
practice  largely  depends.  Before  taking  up  the  study  of  infant 
feeding  the  student  should  read  carefully  the  section  on  Milk. 

Infancy  is  that  period  of  life  dating  from  birth  to  about  two  and 
one-half  years.  Childhood  is  the  period  from  two  and  one-half  years 
to  puberty.  The  theory  that  infancy  ends  at  two  and  one-half  years 
is  an  arbitrary  one. 

There  are  four  methods  of  feeding  infants :  1.  Breast-  or  maternal 
feeding.  2.  Wet-nursing.  3.  Mixed  feeding — i.  e.,  breast-feeding 
supplemented  by  bottle-feeding.     4.  Bottle-  or  artificial  feeding. 

Breast  Feeding. — The  milk  from  a  healthy  mother  is  by  far  the 
best  nourishment  for  an  infant  during  the  first  year  of  its  life,  and 
cannot  be  fully  replaced  by  any  other  form  of  feeding.  Infants  fed 
on  the  breast  milk  of  a  healthy  woman  are  stronger  and  better  able 
to  resist  disease.  They  are  more  apt  to  live  through  the  first  year  of 
life,  are  almost  free  from  the  scourge  of  the  severe  infant  diarrheas. 
This  is  particularly  true  of  the  poorer  classes  who  often  lack  both 
the  time  and  the  intelligence  required  to  rear  a  healthy  baby  by 
•bottle  feeding.  While  it  is  undoubtedly  true  that  babies  may  be 
reared  on  artificial  foods  and  remain  "healthy  and  grow  strong,  the 
percentage  of  robust  bottle  fed  babies  is  much  smaller  than  that  of 
healthy  breast  fed  infants. 

Contraindications  to  Maternal  Nursing. — The  mother  should  not 
nurse  the  child  if  she  has  tuberculosis  in  any  form,  as  she  not  only 
exposes  the  child  to  infection,  but  hastens  the  progress  of  the  disease 
in  herself.  If  she  has  pulmonary  tuberculosis,  nursing  the  child  will 
almost  certainly  prove  fatal  to  her. 

When  the  mother  has  had  any  severe  complication  late  in  pregnancy 
or  in  connection  with  parturition  she  should  not  suckle  her  child. 
Examples  are  nephritis,  convulsions,  severe  hemorrhage  or  septic 
infection. 

Nursing  is  contraindieated  if  the  mother  is  choreic  or  epileptic. 

When  no  milk  is  secreted  nursing  is,  of  course,  impossible.  When 
the  mother  has  shown  on  two  previous  occasions  under  favorable 
conditions  that  she  is  unable  to  nourish  her  child  a  third  attempt 
may  be  made,  but  the  child  should  be  very  closely  watched  and  not 
allowed  to  suffer  from  underfeeding  in  case  no  milk  is  secreted. 

Education    of    the    Mother. — Physicians,    nurses    and    the    various 

251 


252  INFANT  FEEDING 

agencies  for  health  education  have  done  much  and  can  do  more  to 
impress  upon  the  mother,  particularly  during  the  latter  months  of 
pregnancy,  that  maternal  feeding  is  the  normal,  natural,  safe,  and 
easy  way  to  nourish  the  baby.  If  there  is  any  tendency  to  evade 
the  responsibility  the  question  should  be  carefully  explained,  calling 
attention  to  the  higher  death  rate,  the  fact  that  most  of  the  babies 
who  die  during  the  first  year  of  life  of  diarrheal  diseases  are  bottle 
fed.  Many  a  child  is  weaned  for  trivial  reasons  because  the  im- 
portance of  breast  feeding  is  under-estimated  and  many  are  weaned 
because  of  a  lack  of  knowledge  as  how  to  best  meet  some  of  the 
surmountable  difficulties  sometimes  encountered.  The  following 
points  will  be  found  helpful : 

The  Care  of  the  Nipples. — Before  the  child  is  born  the  breasts 
should  be  inspected  and  if  the  nipples  are  short  and  retracted  they 
should  be  lengthened  by  making  gentle  traction  on  them  by  pulling 
the  nipple  out  with  the  fingers  several  times  a  day.  The  results  are 
usually  satisfactory,  A  breast  pump  may  be  used  or  a  baby  employed 
to  suck  on  the  nipples  to  elongate  them.  Occasionally  the  nipples 
are  too  large  and  a  breast  shield  of  proper  size  has  to  be  used  until 
the  child  grows  sufficiently  large  to  take  the  nipple  satisfactorily. 

The  nipples  should  be  washed  off  with  sterile  water  or  boric  acid 
solution  and  dried  before  and  after  every  nursing.  If  the  nipples 
show  any  tendency  to  become  dry  and  crack  between  nursings  a  very 
mild  boric  acid  ointment  or  plain  vaseline  may  be  used  to  keep  them 
soft. 

Tender  nipples  are  best  treated  by  applying  half  alcohol  and  half 
water. 

Cracked  or  fissured  nipples  are  best  treated  by  having  the  child 
nurse  through  a  nipple  shield.  The  fissure  may  be  painted  with  the 
compound  tincture  of  benzoin  or,  if  necessary,  touched  with  one  or 
two  per  cent,  solution  of  nitrate  of  silver. 

Tender  and  inflamed  breasts  are  best  treated  by  supporting  the 
breast  and  the  application  of  cold.  The  breast  should  be  kept  empty 
by  means  of  a  breast  pump,  or  by  having  the  child  nurse  it.  If  there 
is  any  pus  in  the  milk  the  child  should  not  nurse. 

The  Nursing  Mother. — The  regulation  of  her  life  is  of  the  utmost 
importance.  The  essentials  are  plenty  of  rest,  at  least  eight  hours 
in  bed  at  night,  and  an  hour 's  nap  in  the  day-time ;  a  daily  bath,  a 
daily  walk  in  the  open  air,  and  as  much  out-of-door  life  as  is  consistent 
with  her  mode  of  life.  Over-work  and  extreme  fatigue  should  be 
avoided,  as  should  worry.  Some  pleasant  recreation  should  form 
part  of  each  day  if  it  is  possible.  Extreme  emotions,  anger,  grief, 
and  the  like  are  bad  for  the  milk,  while  contentment  and  an  at- 
mosphere of  happiness  favor  lactation.  Constipation  should  be 
avoided  by  dietary  measures  and  as  few  drugs  taken  as  possible. 

The  diet  should  be  of  plain  nutritious  foods.     There  is  no  need  to 


GALACTOGOGUES  253 

make  unnecessary  restrictions.  We  instruct  the  mothers  to  eat  plenty 
of  plain  meats,  eggs,  vegetables,  cereals,  bread  and  butter,  fruits  and 
simple  desserts.  To  drink  milk,  a  (luart  a  day  if  it  can  be  done 
without  disturbing  digestion,  and  six  or  eight  glasses  of  water.  Part 
of  the  milk  can  be  taken  in  cocoa.  Tea  or  coffee  in  moderation,  pref- 
erably once  a  day.  Avoid  any  food  which  she  knows  gives  her  in- 
digestion and  rich  and  complicated  dishes.  Moderate  amounts  of 
salad  may  be  allowed  but  only  if  they  agree  and  with  very  simple 
and  not  too  acid  dressings.  Spices,  mustard,  and  highly  spiced  foods 
occasionally  cause  colic  in  the  baby  and  sometimes  this  follows  the 
ingestion  of  fruits  containing  aromatic  substances ;  in  which  case  they 
are  to  be  avoided. 

Sufficient  calcium  should  be  supplied  and  cheese,  milk,  the  legumes, 
oatmeal  and  almonds  are  all  rich  in  calcium.  (See  also  Metabolism 
and  Oxaluria.) 

Galactogogues. — There  are  no  galactogogues  known  of  positive 
value,  but  we  prescribe  the  thick  malt  extracts,  a  tablespoonful  three 
times  a  day  taken  in  cold  water  or  on  bread  and  butter  in  cases  where 
the  milk  is  poor  or  deficient  in  quantit^^  Where  the  fat  is  deficient 
plenty  of  butter,  cream  and  olive  oil  may  be  added  to  the  diet.  If 
the  mother  is  under-nourished  these  means  are  of  great  service.  If 
the  mother  is  well  nourished  they  tend  to  form  fat  and  should  be  used 
with  caution  or  not  more  than  would  be  in  the  ordinary  diet. 

Hoobler  has  found  that  diets  containing  milk  proteins  and  animal 
proteins  are  better  for  producing  milk  than  those  containing  vegeta- 
ble proteins,  with  the  exception  that  nut  protein  seemed  as  efficient 
as  meat  proteins  in  this  regard.  The  best  results  were  obtained  on 
a  nutritive  ration  of  1:6,  that  is,  the  ratio  between  the  digestible 
proteins  to  the  digestible  carbohydrates  and  fats  and  that  the  diets 
between  2600  and  2900  calories  per  day  produced  better  results  than 
those  containing  3400  or  3700  a  day  while  those  under  2000  were 
inadequate.  The  overfeeding  did  not  increase  the  milk.  Cows'  milk 
protein  was  found  to  be  the  best  form  to  increase  the  milk  production 
and  protect  the  mother's  tissues. 

Reestablishment  of  Lactation. — Where  nursing  has  been  abandoned 
it  may  be  advisable  to  attempt  to  reestablish  the  flow  of  milk  and 
this  may  also  be  done  when  nursing  has  not  been  attempted  at  all. 
The  child  should  be  put  to  the  breast  at  regular  intervals  and  allowed 
to  nurse,  which  it  will  do  under  protest,  as  there  is  no  milk.  The 
child  should  then  be  fed  on  the  proper  substitute  feeding  and  the 
breast  thoroughly  emptied  by  milking.  The  breast  is  milked  from 
about  one  inch  behind  the  areola  forward  to  the  nipple,  and  the 
breast  pulled  downward  and  forward.  The  trick  of  manual  expres- 
sion of  the  milk  is  easily  learned.  The  breast  back  of  the  larger  milk 
ducts  need  not  be  touched  in  this  procedure.  The  regular  nursings 
and  milking  should  be  persisted  in  and  as  the  milk  flow  begins  to  be 


254  INFANT  FEEDING 

established  the  child  may  be  weighed  and  the  difference  between  the 
needed  food  and  the  amount  derived  from  the  mother  made  up  by- 
artificial  feeding.  Varying  lengths  of  time  may  be  needed  to  re- 
establish the  milk  flow  and  it  may  be  a  couple  of  months  before  the 
complete  supply  is  obtained. 

Conditions  Aflfeeting  Woman's  Milk. — Menstruation. — In  most  in- 
stances the  milk  remains  unaffected.  In  something  under  ten  per 
cent,  there  may  be  some  intestinal  indigestion  and  in  about  one-third 
of  these  there  may  be  some  gastric  disturbance  with  occasional  vomit- 
ing. In  some  cases  there  is  nervousness  and  irritability  without  any 
distinct  gastro-intestinal  disturbance.  Menstruation  is  no  contra- 
indication for  nursing. 

*  Pregnancy. — If  the  mother  becomes  pregnant  the  child  should  be 
weaned.  The  milk  becomes  poor  and  if  toxemia  is  present  it  may 
contain  substances  which  may  poison  the  child. 

^jy^ntitoxin. — Diphtheria  and  other  antitoxins  are  eliminated  in  the 
milk.  There  are  probably  antitoxic  or  similar  substances  normally 
in  the  milk  which  may  explain  the  well-known  immunity  of  nursing 
infants  to  most  infectious  diseases.  Very  little  is  known  about  this 
subject  at  the  present  time. 

Bacteria. — A  few  bacteria  are  usually  found  in  the  milk,  but  may 
be  disregarded.  In  advanced  tuberculosis  or  in  tuberculosis  of  the 
mammary  gland  tubercle  bacilli  may  be  present.  In  septic  conditions 
and  in  breast  infections  the  invading  organism  may  be  found  in  the 
milk. 

Alcohol. — Unless  taken  in  very  large  quantities  alcohol  is  not  ex- 
creted in  the  milk.  Beer  or  other  malt  liquors  are  often  used  to 
increase  the  quantity  of  milk.  The  fat  in  the  milk  is  usually  in- 
creased as  well,  but  in  some  eases  no  effect  is  noted  or  the  mother 
gains  in  weight. 

Drugs. — Belladonna  and  its  derivatives  administered  to  the  mother 
are  excreted  in  the  milk.  Salvarsan  is  excreted  in  the  milk  and  af- 
fects the  infant  usually  favorably,  but  death  of  the  infant  has  been 
supposed  to  be  due  to  the  administration  of  the  drug  to  the  mother. 
This  needs  further  study. 

Apart  from  salines  and  perhaps  some  of  the  other  laxatives  which 
may  sometimes  affect  the  child,  few  other  drugs  are  excreted  at  all 
except  in  traces  which  are  of  no  importance.  After  long  continued 
use  mercury,  arsenic,  bromides,  salicylates,  hexamethylenamin  and 
the  iodides  may  appear  sometimes  in  sufficient  quantities  to  affect  the 
child. 

Nervous  Impressions. — Any  severe  emotion,  as  fright,  anger  or  grief, 
may  affect  the  quantity  of  the  milk,  or  it  may  be  changed  in  some 
way  so  that  the  child  may  become  ill. 

Ferments  and  Other  Substances. — Various  ferments  have  been  de- 


CARE  OF  THE  BREASTS 


255 


scribed  in  the  milk,  but  these,  vitamins,  fat  soluble  A,  water  soluble 
B,  poisons  and  proteins  which  produce  hypersensibility  in  the  infant 
are  not  thoroughly  understood  at  this  time. 

Care  of  the  Breasts. — If,  for  any  reason,  the  child  is  weaned  while 
the  milk  supply  is  still  ample  the  best  method  of  treating  the  breasts 
is  to  have  them  slightly  supported  by  a  bandage  underneath  and 
then  let  them  absolutelj'^  alone.  The  breasts  will  fill  full  of  milk, 
become  very  hard  and  slightly  tender,  then  the  milk  secretion  will 
stop  and  the  breasts  gradually  return  to  normal.  If  the  breast  is 
not  interfered  with  it  will  take  care  of  itself  very  much  better  than 
if  various  manipulations  are  used.  In  cases  of  localized  painful 
swellings  a  breast  pump  may  be  used  to  remove  the  milk  or  another 
baby  substituted  if  that  is  possible.  Applications  of  cold  afford 
greater  relief  from  the  pain  than  anything  else. 

The  Intervals  for  Feeding. — On  this  point  there  are  many  and 
diverse  opinions.  The  interval  must  be  suited  to  the  individual  baby. 
"We  believe  that  feeding  regularly  every  three  hours  during  the  day 
and  the  night  feeding  as  stated  above  will  meet  the  requirements  of 
most  babies  better  than  any  fixed  rule.  This  may  be  started  on  the 
third  day.  If  the  baby  does  not  gain,  is  fretful  or  shows  any  other 
signs  of  insufficient  food  the  interval  may  be  decreased  to  two  and 
a  half  hours  or  even  to  two  hours  and  a  little  later  the  interval 
lengthened.  If  the  baby  cries  from  hunger  regularly  before  the 
feeding  time  it  may  be  fed  at  shorter  intervals  until  it  is  large  enough 
to  take  sufficient  to  last  three  hours.  Very  small  and  premature 
babies  require  shorter  intervals  than  the  large  robust  infants.  After 
seven  or  eight  months  there  is  no  objection  to  trying  a  four  hour 
schedule.  This  may  be  used  earlier  in  many  larger  or  very  robust 
babies  and  in  cases  with  certain  digestive  troubles  it  may  be  tried. 
Many  of  the  best  pediatrists  of  the  country  are  recommending  the 
four  hour  schedule  as  a  routine,  but  we  believe  from  our  experience 
that  the  three  hour  schedule  is  better  as  a  rule. 

Holt's  Schednle  for  Feeding  Healthy  Infants  During  the  First  Year. 


Age. 

Interval 
between 

meals 
by    day. 

Z  I'  _    • 

Number 
of  feed- 
ings in 
2i  hours. 

Second  to  seventh  day   

Second  and  third  weeks 

Fourth  to  ninth  week    

Tenth  week  to  fifth  month 

Fifth   to   seventh   month    

Seventh  to  twelfth  month   

3 
3 
3 
3 
3 
4 

1 
1 

1 
1 

0 
0 

7 
7 
7 
7 
6 
5 

\i--n 

2  -4 

3  -4i 
3i-5 
4i-6* 
64-9 

10-17 
14-28 
21-31 
24-35 
27-39 
33-45 

For  the  smaller  babies  the  following  schedule  from  Holt  may  be 
used  as  a  guide : 


256 


INFANT  FEEDING 


A-e. 


Number  in 

twenty-four 

hours 


Intervals       j,  ^'Sht    nursing 
during    day.   b^-tween    9    p.    m 
"        '  and   7    a.   m. 


1st  day    

2d    day    

3d  to  28th  day  . 
4th  to  13th  week  . 
3d  to  5th  month  . 
5th  to  12th  month 


4 

6  hours 

1 

6 

4      " 

1 

10 

2      •' 

2 

8 

2i    " 

1 

7 

3      " 

1 

6 

3      " 

0 

Testing  the  Milk.— Mother 's  milk  may  easily  be  tested  by  means 
of  Holt's  milk  set,  which  consists  of  a  lactometer  and  a  cream  gauge. 
(This  may  be  had  from  Eimer  &  Amend,  New  York.)  With  this  the 
specific  gravity  and  the  amount  of  cream  may  easily  be  estimated. 
Estimated  with  this  instrument  the  cream  is  to  the  fat  as  5  is  to  3. 

In  taking  a  specimen  of  milk  the  child  should  be  allowed  to  nurse 
a  little  and  about  the  middle  of  the  nursing  chosen.  The  first  milk 
drawn  is  much  weaker  in  fat  and  richer  in  protein  than  the  average, 
while  the  last  is  richer  in  fat  and  weaker  in  protein. 


Normal  average    .   .  . 
Healthy  variations .   . 

Healthy  variations .   . 

Unhealthy  variations 

Variations 

Variations 

Variations 

Variations 

Variations 


Specific 

gravity, 

70°  F. 


1.031 
1.028-1.029 


1.032-1.033 
Below  1.028 


Below  1.028 
Below  1.028 


Above  1.033 


Above  1.033 
Above  1.033 


Cream,  twenty-four 
hours. 


7  per  cent. 
9-12  per  cent. 

5-6  per  cent. 

High  (above  10  per  cent.). 

Normal  (5-10  per  cent.). 
Low  (below  5  per  cent.). 

High. 

Normal. 
Low. 


Proteins. 


1.5  per  cent. 
Normal  (rich 

milk). 
Normal  (fair 

milk). 
Normal  or  slightly 

below. 
Low. 
Very  low  (very 

poor  milk). 
Very  high  (very 

rich  milk). 
High. 
Normal  or  nearly 


Modifying  Mother's  Milk.— There  are  several  ditferent  types  of 
milk  met  with  and  the  following  suggestions  will  be  found  of  use : 

1. — If  the  mother's  milk  is  too  rich  it  may  usually  be  modified 
by  limiting  the  diet,  especially  the  amount  of  meat  taken  and  pro- 
hibiting all  alcoholic  and  malted  drinks.  The  mother  should  be  out 
of  doors  as  much  as  possible  and  exercise,  preferably  walking  to  the 
point  of  fatigue,  is  to  be  advised.  These  measures  nearly  always 
bring  about  the  lowering  of  fats  and  proteins.  In  cases  of  infants 
with  feeble  digestive  powers,  one  or  two  ounces  of  water  may  be  given 
just  before  nursing.  In  some  severe  cases  the  child  must  be  partially 
fed  on  other  food  for  a  limited  period. 

2. — When  the  milk  is  of  good  quality,  but  deficient  in  quantity,  the 
amount  may  generally,  but  not  always,  be  increased  by  the  following 
measures:  The  mother  should  have  nine  or  ten  hours'  rest  in  bed 
at  night  and  a  nap  of  an  hour  or  so  during  the  day.  She  should  be 
out  of  doors  as  much  as  possible  and  as  far  as  it  can  be  done  she 


OXE  BOTTLE  A  DAY  257 

should  be  relieved  of  her  household  cares  and  duties.  Every  day,  if 
she  is  able,  she  should  take  a  short  walk  out  of  doors.  The  diet 
should  be  ample  with  meat,  eggs,  cereals,  vegetables,  and  simple 
desserts.  The  amount  of  fluid  ingested  is  important  and  above  what 
she  would  ordinarily  take  she  should  be  given  something  over  the 
amount  that  would  be  secreted  in  the  milk,  from  one  quart,  one  and 
one  half  quarts,  or  even  two  quarts.  This  may  be  given  as  milk, 
cocoa,  very  weak  tea  (but  not  too  much  of  this),  or  plain  water. 
In  women  of  suitable  nationality  and  disposition  malted  liquors,  such 
as  beer,  porter  or  stout  may  be  used,  but  always  bearing  in  mind 
that  possibility  of  starting  the  alcohol  habit.  The  breasts  should  be 
massaged  twice  daily  for  five  or  ten  minutes.  Malt  extracts,  the  thick 
ones,  may  also  be  given,  a  tablespoonful  in  cold  water  three  times  a 
day  at  meal  times.  Iron  will  be  needed  in  anemic  women.  Olive  oil 
and  cream  may  often  be  used  to  advantage.  In  some  women  the 
extra  food  causes  an  increase  in  weight  rather  than  in  the  milk. 
While  waiting  to  see  if  the  milk  will  be  improved  the  child  should 
not  be  forgotten,  but  should  receive  supplementary  feedings. 

3.- — When  the  milk  is  poor  in  quality  regardless  of  the  quantity 
very  little  can  be  done  and  we  no  longer  waste  time  in  this  class, 
but  wean  at  once. 

4. — There  are  some  cases  in  which  the  milk  appears  to  be  normal 
and  yet  for  some  undiscoverable  reason  the  child  does  not  thrive. 
There  is  no  gain  in  weight  and  the  child  is  anemic,  fretful,  sleepless, 
and  often  vomits  and  has  abnormal  stools.  These"  cases  should  be 
weaned  after  a  fair  trial  has  been  made  to  improve  the  condition. 
If  the  child  is  gaining  a  little,  often  much  may  be  accomplished  by 
supplementary  feedings. 

One  Bottle  a  Day. — A  moot  point  is  whether  it  is  wise  to  allow  the 
child  one  bottle  a  day  as  a  routine  practice.  The  authors  always 
follow  this  plan  after  the  second  month  should  it  be  deemed  advisable 
in  the  case  in  hand,  and  where  proper  precautions  regarding  cleanli- 
ness and  pasteurization  have  been  taken,  no  ill  results  have  been  seen 
to  follow.     The  advantages  of  this  method  are  as  follows : 

The  child  learns  to  take  milk  from  a  bottle,  and  if,  owing  to  the 
illness  of  the  mother,  it  becomes  necessary  at  any  time  to  substitute 
the  bottle,  this  may  be  done  without  much  difficulty.  On  the  other 
hand,  if  the  child  has  taken  nothing  but  the  breast,  it  may  often 
refuse  the  bottle  entirely,  with  disastrous  results,  severe  cases  of 
inanition  having  been  known  to  follow.  This  method  facilitates 
weaning.  If  the  mother  is  weak,  it  allows  her  to  obtain  an  undis- 
turbed night's  rest.  Among  the  upper  classes  the  child  is  often 
weaned  early  so  that  nursing  may  not  interfere  with  the  mother's 
social  pleasures  and  duties.  If  the  breast-feeding  be  supplemented 
by  the  bottle,  many  of  these  women  may  be  induced  to  nurse  their 
children  during  the  greater  part  of  the  first  year,  when  thev  would 
17 


258  INFANT  FEEDING 

otherwise  give  it  up  very  early  and  abandon  the  child  to  the  care  of 
a  nurse. 

The  First  Few  Days. — The  first  few  days  of  the  baby 's  life  are  very 
important  ones  and  many  of  the  subsequent  troubles  may  be  directly 
traced  to  an  inadequate  supervision  of  the  child  during  this  period. 
This  happens  not  only  among  the  ignorant  and  ill-informed,  but  also 
in  the  most  intelligent  classes  and,  curiously  enough,  all  too  fre- 
quently in  otherwise  more  or  less  satisfactory  lying-in  hospitals. 

During  the  first  forty-eight  hours  the  child  receives  practically  no 
nourishment  from  the  breast,  the  only  fluid  secreted  during  this 
time  being  colostrum.  This  has  a  laxative  effect  upon  the  infant's 
bowels,  emptying  them  of  the  dark  brownish  material,  known  as 
meconium,  that  has  accumulated  in  the  intestinal  canal  during  uterine 
life.  The  child  should,  however,  be  put  to  the  breast  at  regular  in- 
tervals, so  as  to  establish  a  free  flow  of  milk;  this  generally  begins 
on  the  third  day,  but  may  be  delayed.  During  the  first  two  days 
after  birth  the  child  gets  about  six  ounces  of  colostrum  a  day,  which 
is  all  that  is  needed  in  the  way  of  food.  It  may,  however,  be  given 
a  teaspoonful  or  two  of  warm  boiled  water  or  of  a  5  per  cent,  solution 
of  sugar  of  milk.  Catnip,  fennel  tea  and  the  like  should  not  be 
given.  In  unusually  robust  but  fretful  children,  or  when  there  is 
fever  a  small  amount  of  food  may  be  required,  and  this  may  be  given 
according  to  the  rules  for  artificial  feeding.  If  the  child  is  very 
small  or  premature  follow  the  rules  for  feeding  premature  infants. 

The  importance  of  emptying  the  breasts  at  regular  intervals  cannot 
be  too  strongly  insisted  upon.  This  is  the  greatest  stimulation  to 
milk  secretion  that  there  is,  not  only  during  the  first  few  days  but 
during  the  whole  of  lactation.  The  breast  is  automatic  and  supplies 
the  demands  made  upon  it.  If  no  milk  is  taken  out  none  comes  in. 
If  the  child  is  too  feeble  to  nurse  vigorously  and  for  this  reason  more 
in  need  of  maternal  nursing  than  ever  the  colostrum  may  not  be 
removed  from  the  breasts  and  the  secretion  of  the  milk  seriously 
interfered  with.  In  such  cases  a  healthy  infant  may  be  used  to 
empty  the  breasts  or  a  breast  pump  may  be  employed  or  the  milk 
expressed  by  hand.  The  breasts  should  be  nursed  alternately  in 
order  that  each  one  shall  be  properly  emptied.  All  through  lacta- 
tion if  the  breasts  are  not  emptied  there  is  a  tendency  for  the  milk 
to  become  poor  in  quality.  Many  mothers  who  have  little  milk  at- 
tempt to  save  it,  which  is  a  great  mistake,  for  like  the  widow's  cruse 
the  more  that  is  taken  out  the  more  comes  in. 

The  milk  secretion  usually  begins  after  the  first  forty-eight  hours 
and  from  this  time  the  normal  infant  begins  to  gain  in  weight.  This 
is  a  most  critical  period,  for  all  too  often  after  a  few  trials  at  nursing 
and  no  milk  coming  in  the  breast  the  child  is  weaned  when  with  a 
little  patience  the  milk  supply  could  be  established.  Usually  when 
the  milk  comes  in  the  breast  there  is  ample  evidence  of  it.     It  flows 


I 


THE  FIRST  FEW  DAYS  259 

easily  from  the  nipple,  the  breast  fills  up  and  the  difference  before 
and  after  nursing  is  very  apparent.  In  some  cases  it  may  be  difficult 
to  tell  whether  the  milk  is  coming  in  or  not  and  in  case 'of  doubt  the 
child  may  be  weighed  immediately  before  and  after  nursing.  The 
child  should  be  put  to  the  breast  at  regular  intervals  for  at  least  a 
week  in  cases  in  which  the  milk  tiow  is  delayed  or  scanty.  If  no 
milk  is  secreted  by  that  time  the  child  can  be  weaned  and  also  if  the 
milk  is  very  scanty  and  very  poor  in  quality.  This  should  not  be 
done,  however,  until  a  thorough  trial  has  baen  made  during  which  the 
breast  is  completely  emptied.  '  Massage  of  the  breast  twice  a  day 
for  five  minutes  is  of  benefit. 

During  this  Time  the  Child  should  not  be  Neglected. — It  needs 
food  after  the  first  forty-eight  hours  and  after  nursing  if  it  receives 
little  or  nothing  the  feeding  should  be  supplemented  with  the  proper 
amount  in  a  bottle.  The  amount  may  be  regulated  according  to  the 
general  rules  for  infant  feeding.  If  the  child  vomits  immediately 
after  feeding  it  is  generally  due  to  too  much  being  given;  and  the 
amount  can  be  reduced.  Another  plan  is  to  weigh  the  baby  before 
and  after  feeding  and  the  difference  between  the  normal  feeding  and 
the  amount  taken  from  the  breast  given.  The  weighing  should  not 
be  done  in  the  presence  of  the  mother,  as  it  is  apt  to  make  her 
nervous. 

The  food  supplied  should  be  according  to  the  general  rules  for 
infant  feeding,  but  if  breast  milk  can  be  secured  we  prefer  it  to  all 
other  food.  As  so  many  children  are  born  in  lying-in  hospitals  these 
days  this  can  often  be  secured  without  difficulty. 

In  all  doubtful  cases  the  child  should  be  weighed  daily  until  it  is 
gaining  and  the  feeding  definitely  established.  After  this  twice  a 
week  for  a  few  weeks,  and  then  once  a  week  is  sufficient.  In  weighing 
the  child  it  should  be  done  with  accurate  scales,  the  child  should  be 
stripped,  and  it  should  be  weighed  at  the  same  time  every  day  and 
under  the  same  conditions  as  regards  the  time  of  nursing,  the  empty- 
ing of  the  bladder  and  bowels.  A  change  of  several  ounces  can  be 
seen  by  weighing  a  child  with  an  empty  stomach,  empty  bladder  and 
bowels  one  day  and  with  the  reverse  conditions  the  next. 

If  the  child  is  not  getting  sufficient  food  it  does  not  gain  or  even 
loses  weight.  It  is  fretful,  worried  and  cross.  If  the  child  is  getting 
too  little  milk  of  a  good  quality  it  is  fretful  and  gains  slowly  or  not 
at  all,  but  there  is  rarely  any  disturbance  of  stomach  or  bowels  un- 
less the  quantity  is  much  too  little.  If  the  milk  is  very  deficient  in 
quality  or  both  or  for  some  reason  unsuited  for  the  child  there  are 
alimentary  disturbances,  usually  a  diarrhea  with  greenish  stools  con- 
taining a  large  amount  of  mucus  and  often  undigested  curds.  Some- 
times the  stools  are  brownish  with  small  curds  the  size  of  a  grain  of 
wheat  or  larger.  Earely  there  is  constipation  with  small  hard  dry 
stools  often  associated  with  colic.     There  may  also  be  vomiting  of 


260  INFANT  FEEDING 

small  amounts  of  milk  mixed  with  mucus  and  colic  due  to  gas  in  the 
stomach  or  intestines  or  both. 

Care"  should  be  taken  to  differentiate  the  cases  which  are  not  getting 
sufficient  milk  from  those  in  which  the  milk  disagrees — when  the  milk 
is  scanty  the  child  wants  to  nurse  for  a  long  time,  a  half  hour  or 
longer  or  it  may  nurse  a  few  moments  and  then  turn  from  the  breast 
with  evident  disgust  and  anger. 

Usually  after  a  week  or  so  normal  conditions  obtain,  but  if  they 
do  not  the  problem  of  what  the  feeding  of  the  child  is  to  be  must  be 
settled.  Experience  helps  a  great  deal  and  a  careful  weighing  of  the 
evidence  at  hand,  the  general  condition  of  mother  and  child  and  the 
examination  of  the  mother's  milk,  will  usually  point  the  way  more 
or  less  clearly.  If  the  mother's  milk  is  of  good  quality  but  scanty 
and  the  child  is  gaining  on  mixed  feeding  this  should  be  continued, 
using  every  effort  to  increase  the  mother's  milk.  If  the  milk  is  very 
poor  in  quality  the  child  should  be  weaned.  If  the  mother's  milk  is 
apparently  normal  or  of  good  quality  but  scanty,  and  the  child  is 
doing  badly,  with  loss  of  weight,  stationary  weight,  colic,  vomiting, 
diarrhea,  or  undigested  stools,  the  child  should  be  put  on  artificial 
feeding  for  a  few  days  and  the  mother's  milk  kept  going  by  using 
the  breast  pump  or  hand  expression.  If  the  symptoms  cease  and  the 
child  does  well  it  should  be  weaned.  If  it  does  not  do  any  better  and 
the  usual  changes  in  the  milk  do  not  bring  about  an  improvement  we 
continue  mixed  feeding  a  little  longer  or  try  to  get  some  other 
human  milk  and  see  if  the  baby  does  well  on  that  while  it  does  badly 
on  its  mother's  milk.  If  this  is  the  case  the  child  should  be  weaned. 
If  the  child  is  to  be  weaned  it  is  important  to  do  it  before  too  much 
damage  is  done  to  its  gastro-intestinal  tract  and  nutrition,  as  it  makes 
the  subsequent  feeding  easier. 

The  mental  attitude  of  the  mother  has  a  marked  effect  on  the  milk 
secretion,  and  if  she  has  been  properly  instructed  and  encouraged 
beforehand,  there  is  usually  no  difficulty.  If,  on  the  other  hand,  she 
has  grave  doubts  as  to  her  capability,  and  particularly  if  she  hears 
both  physician  and  nurse  discuss  her  probable  incompetency,  the  milk 
secretion  may  be  inhibited.  The  mental  condition  of  the  mother  is 
often  affected  as  the  result  of  weighing  the  child.  It  is  very  desirable 
that  the  child  be  weighed  regularly  and  the  weight  recorded;  but  if 
the  mother  is  at  all  nervous,  or  if  the  child  is  not  doing  well,  the 
weighing  should  not  be  done  by  the  mother  or  in  her  presence.  A 
loss  in  weight,  or  even  the  fact  that  there  is  no  material,  gain,  may  so 
affect  the  mental  condition  of  the  mother  as  to  prove  deleterious  to 
the  secretion  of  milk.  With  proper  encouragement  and  by  stimulat-' 
ing  the  breast  by  placing  the  child  at  it  at  regular  intervals  the  flow 
of  milk  is  promoted. 


BREAST  FEEDING  261 

The  subject  of  the  fitness  of  mothers  for  nursing  their  infants  is 
receiving  more  attention  of  late  years,  luid  in  Germany  an  attempt 
has  been  made  to  show  that  the  daughters  of  alcoholic  parents  or 
ancestry  are  apt  to  be  incapable  of  nursing  their  infants.  While  this 
has  been  proved  statistically,  an  alcoholic  ancestry  is  of  so  common 
occurrence  that  almost  any  existing  evil  might  be  attributed  to  it 
and  its  relationship  proved. 

Many  mothers  with  an  abundance  of  maternal  love  and  manifold 
good  intentions  are  often  lacking  in  intelligence  and  cannot  be  taught 
the  proper  care  of  an  infant. 

Breast-nursing  often  proves  a  failure  because  the  mother  does  not 
understand  how  to  give  the  breast  to  the  child.  With  the  increase  in 
civilization  there  seems  to  be  a  diminution  in  instinct,  and  careful 
directions  should  be  given  in  every  case.  The  child  should  lie  on  the 
left  or  right  arm,  according  to  whether  the  child  is  to  nurse  at  the 
left  or  right  breast.  If  the  mother  is  in  a  sitting  posture  the  body 
should  be  inclined  slightly  forward.  With  her  free  hand  she  should 
grasp  the  breast  near  the  nipple  between  the  first  two  fingers.  If, 
owing  to  the  free  flow  of  milk,  the  child  takes  the  milk  too  rapidly, 
this  may  be  checked  by  slight  pressure  of  the  fingers.  The  child 
should  nurse  until  satisfied.  The  contents  of  one  breast  are  generally 
sufficient  for  one  nursing,  and  the  breasts  should  be  used  alternately. 
When  satisfied,  the  infant  will  usually  fall  asleep  at  the  breast. 
Under  ordinary  conditions  the  nursing  should  last  from  about  ten 
to  twenty  minutes.  If  the  milk  is  taken  too  rapidly,  vomiting  may 
ensue  immediately  after  or  during  feeding.  If  too  much  is  taken,  it 
is  regurgitated  almost  immediately.  If  the  infant  consumes  more 
than  half  an  hour  in  nursing,  the  breast  and  milk  should  be  examined. 
As  the  infant  grows  older  it  requires  and  takes  more  food,  and  con- 
sequently will  require  a  longer  time  to  nurse  than  it  did  during  the 
early  days  of  life. 

The  inculcation  of  good  nursing-habits  cannot  be  too  strongly  in- 
sisted upon.  Many  attacks  of  colic,  indigestion  and  diarrhea  may  be 
traced  to  improper  nursing.  When  good  habits  are  once  established, 
there  is  generally  very  little  trouble,  the  success  of  the  training  de- 
pending largely  on  the  manner  in  which  it  is  done.  Regular  hours 
for  feeding  should  be  fixed  and  adhered  to ;  and  if  the  child  is  asleep 
at  the  feeding-hour,  it  may  be  aroused,  for  it  will  almost  invariably 
go  to  sleep  after  nursing.  After  the  last  feeding,  which  should 
usually  take  place  at  9  or  10  o'clock,  the  child  should  be  quieted  and 
allowed  to  sleep  as  long  as  it  chooses. 

During  the  first  month  or  two  the  infant  will,  as  a  rule,  awaken 
between  1  or  2  o'clock  and  again  at  about  4  or  5  o'clock.  After  two 
or  three  months  it  will  require  but  one  night  feeding,  and  after  five 
months  of  age  the  average  infant  will  sleep  all  night  without  nursing. 

When  the  change  is  being  made  and  the  child  awakens  for  its  ac- 


262  INFANT  FEEDING 

customed  nursing,  it  should  be  given  a  little  warm  water  from  a  bottle 
and  be  quieted,  but  not  taken  up.  Regular  nursing-habits  induce 
regular  bowel  movements  and  sleep,  and  the  three  combined  insure 
health  and  comfort  not  only  for  the  infant,  but  for  the  mother  as 
well.  A  healthy  child,  if  trained  to  do  so,  will  sleep  without  rocking 
or  coddling.  Three  things  are,  however,  essential  to  secure  siiccess 
in  this  training :  a  satisfied  appetite,  dry  napkins,  and  a  quiet,  dark- 
ened room.  The  infant  must  not  be  nursed  each  time  it  cries.  If 
it  has  colic,  the  warm  milk  may  soothe  the  child  for  a  time,  but  later 
aggravates  the  trouble,  which  in  many  cases  is  due  to  overfeeding  or 
to  too  frequent  feeding. 

Weaning. — The  child  should  be  weaned  only  for  very  good  reasons 
and  practically  never  for  minor  disturbances,  such  as  colic  or  slightly 
abnormal  stools,  as  long  as  the  child  is  gaining  in  weight.  It  is  not 
necessary  to  wean  the  child  for  cracked  nipples,  as  these,  with  proper 
treatment  and  the  breast  shield,  are  generally  soon  recovered  from. 
The  child  should  not  be  weaned  on  account  of  the  mother's  beginning 
menstruation,  as  this  rarely  has  more  than  a  temporary  effect  on  the 
milk  and  usually  not  even  that ;  nor  should  it  be  done  for  any  of  the 
ordinary  mild  diseases  that  may  occur  in  the  mother.  There  are, 
however,  quite  a  large  list  of  reasons  for  taking  the  child  oflt"  the 
breast,  among  these  being  the  presence  of  any  acute  severe  disease  in 
the  mother  or  of  any  chronic  wasting  disease.  In  cases  where  the  milk 
definitely  does  not  agree  with  the  child  or  where  there  is  no  gain  in 
weight  for  a  considerable  period  or  even  a  loss  of  weight,  the  child  is 
better  fed  -on  artificial  food  than  allowed  to  get  in  a  very  run  down 
condition  from  lack  of  proper  nourishment.  In  very  many  instances 
the  mother  attempts  to  nurse  the  child  for  too  long  a  period  and  after 
the  milk  has  either  failed  in  quantity  or  quality  or  both.  When  the 
milk  begins  to  fail  it  is  a  very  good  plan  to  begin  mixed  feeding  and 
this  may  be  increased  and  the  child  gradually  weaned,  generally  with- 
out any  difficulty  whatever.  As  a  general  rule,  the  weaning  should 
not  be  done  in  summer  if  it  can  be  avoided,  but  the  dangers  of  weaning 
a  child  in  summer  are  very  much  over-estimated ;  provided  it  is  done 
by  some  one  who  understands  the  subject  of  infant  feeding.  The 
chief  danger  of  weaning  in  summer  is  the  same  danger  that  attends 
artificial  feeding  in  general,  and  spoilt  milk.  The  child  should  never 
be  weaned  in  the  spring  if  it  is  doing  well,  for  fear  it  might  have  to 
be  weaned  during  the  summer  months.  If  the  child  has  been  ac- 
customed to  taking  one  bottle  a  day  the  weaning  is  very  easily  ac- 
complished. If  this  has  not  been  the  custom  there  may  be  great 
difficulty  in  getting  the  child  to  take  the  bottle,  in  which  case  the 
child  should  be  fed  by  some  one  else  when  the  mother  is  not  present. 
Weaning  may  be  accomplished  in  two  ways :  either  by  substituting  one 
bottle  for  a  feeding  and  then  two  bottles  until  the  child  is  entirely 
off  the  breast,  or  the  method  advised  in  mixed  feeding  may  be  used, 


WET-NURSING  263 

gradually  iucreasing  the  quantity  until  the  child  is  no  longer  nursed 
at  all. 

Wet-nursing. — With  the  advent  of  a  more  thorough  knowledge  of 
infant  feeding  wet-nursing  has,  fortunately,  become  less  frequent. 
Nevertheless,  there  are  some  infants  that  will  thrive  on  nothing  but 
breast-feeding.  When  this  is  the  case,  a  wet-nurse  must  be  chosen 
according  to  the  following  rules : 

The  woman  should  be  healthy  and  of  good  habits.  The  absence 
of  syphilis,  tuberculosis,  alcoholism,  and  other  diseases  should  be  de- 
termined by  careful  examination.  A  Wassermann  test  should  be 
made  to  determine  the  presence  or  absence  of  syphilis.  The  nipples 
should  be  carefully  examined  for  fissures  and  ulceration.  The  breast 
should  be  examined  before  and  after  nursing,  and  the  milk  tested  as 
previously  described.  The  size  of  the  breast  alone  is  not  a  good  guide 
as  to  the  amount  or  quality  of  the  milk  it  secretes.  The  quantity  may 
be  judged  by  the  size  of  the  breast  before  and  after  nursing  or  by 
weighing  the  baby  before  and  after  nursing.  This  latter  method,  al- 
though a  good  one,  is  not  usually  resorted  to.  The  wet-nurse  should 
always  be  one  who  has  nursed  her  own  child  successfully  for  at  least 
a  month.  If  possible,  she  should  be  a  primipara  between  twenty  and 
thirty-five  years  of  age.  Younger  or  older  women  should  not,  as  a 
rule,  be  employed.  If  the  infant's  condition  permits,  the  nurse  should 
be  given  at  least  a  week's  trial,  for  often  the  change  in  her  mode  of 
living  may  cause  a  scanty  flow  of  milk  or  render  it  otherwise  un- 
satisfactory. When  she  has  become  accustomed  to  her  surroundings, 
the  milk  may  become  perfectly  normal.  Owing  to  idleness  and  a  too 
abundant  diet  the  milk  may  become  too  rich.  In  these  cases  the  rules 
previously  laid  down  may  correct  the  condition.  Suitable  wet-nurses 
are  not  easily  obtained,  are  expensive,  and  are  often  a  source  of  con- 
stant trouble  and  annoyance.  A  woman  who  will  give  up  the  care 
of  her  own  child  for  pay  is  usually  a  very  unpleasant  person  to  have 
about.  For  these  reasons,  except  where  there  is  severe  acute  inani- 
tion, other  means  should  be  tried  before  a  wet-nurse  is  resorted  to. 
Wet-nursing  is,  however,  very  successfully  carried  out  in  some  Euro- 
pean countries. 

Mixed  Feeding. — Children  fed  partly  on  the  breast  and  partly  on 
the  bottle  should  always  be  under  supervision.  This  method  is  in- 
dicated when  the  mother's  milk  is  poor  or  scanty,  owing  to  some  in- 
tervening illness,  or  when  owing  to  deficient  quantity,  the  mother 
cannot  entirely  nurse  the  child.  It  is  also  used  in  weaning.  If  the 
mother  is  nursing  the  child  but  once  or  twice  a  day  the  milk  is 
apt  to  become  very  poor  and  under  these  circumstances  it  should  be 
examined  from  time  to  time.  In  these  cases,Jihe— ehild  is  satisfied 
after  the  bottle  but  not.^il£i_nursing. 

We  usually  allow  one  full  f eeding__a^  day  in  place  of  a  nursing 
and  in  the  ease  of  weak  mothers  and  if  the  child  is  still  getting  a 


264  INFANT  FEEDING 

night  feeding  this  is  best  given  at  night,  otherwise  at  any  time  of 
the  day  that  it  suits  the  mother.  At  each  other  nursing  period  the 
child  is  put  to  the  breast  and  left  long  enough  to  empty  at  least  one 
of  them.  Immediately  after  this  the,  child  may  be  given  a  bottle 
containing  the  amount  necessary  to  make  up  the  feeding.  This  may 
be  gauged  by  the  child's  being  satisfied  and  contented  after  feeding 
or  by  weighing  the  child  before  and  after  the  feeding  and  giving  the 
difference  between  what  it  takes  at  the  breast  and  a  normal  size 
feeding  for  the  baby  in  question.  If  too  much  is  given  it  will  be 
vomited  within  a  short  time  after  feeding. 

Partial  Feeding  with  Human  Milk. — It  frequently  happens  that  a 
wet  nurse  cannot  be  obtained,  but  nearly  always  it  is  possible  to  get 
one  or  more  nursings  from  some  friendly  mother.  From  1  to  6  or  8 
ounces  of  breast  milk  added  to  the  diet  of  the  artificially  fed  child  is 
often  the  means  of  saving  the  life  of  the  child — the  breast  milk 
stimulating  the  nutrition  as  nothing  else  will.  In  cities  such  milk  can 
often  be  bought  at  maternity  hospitals  by  making  special  arrange- 
ments, and  a  similar  plan  may  be  successfully  followed  apart  from 
hospitals.  In  premature,  improperly  fed  young  infants,  inanition, 
marasmus,  and  in  some  other  conditions  this  plan  is  of  great  value. 
(See  Hoobler,  Journal  of  the  American  Medical  Association,  Aug.  11, 
1917,  p.  421.) 

Other  Foods  Allowed. — Beginning  at  eight  or  nine  months  the  follow- 
ing articles  of  diet  may  generally  be  added  to  advantage.  Care 
should  be  taken  to  see  that  not  too  much  is  given  at  the  start  and 
that  the  various  articles  are  well  digested  and  well  borne. 

Puree  of  milled  spinach 

Puree  of  potato 

Strained  broth  thickened  with  any  cereal 

Vegetable  puree  added  to  soups  (see  same  for  preparation) 

Oatmeal,  wheat,  rice  or  barley  jelly 

Orange  juice 

Prune  juice 
Artificial  or  Bottle  Feeding.— If  a  baby  cannot  be  nursed  at  the 
breast,  how  can  it  be  fed  so  as  to  have  it  grow  into  a  strong,  healthy, 
normal  child?  This  question  has  been  the  object  of  a  great  deal  of 
study,  and  while  much  has  been  learned  about  infant  feeding,  it  would 
seem  that  there  is  much  more  to  find  out.  The  earlier  methods  of 
modifying  milk  consisted  of  mixing  mixtures  of  water  and  milk,  then 
sugar  and  water  were  added,  and  then  cereal  gruels  with  or  without 
sugar.  Buttermilk  mixtures  were  used  in  some  places.  Liebig  tried 
to  get  a  mixture  to  add  to  milk  to  adapt  it  to  the  infant's  digestion. 
Biedert  and  Meigs  suggested  mixtures  to  replace  mothers'  milk,  and 
Rotch  elaborated  their  ideas  and  suggested  the  study  of  milk  mixtures 
from  the  standpoint  of  the  percentage  of  protein,  fat,  and  carbo- 
hydrate  contained.     Budin   and   others  suggested   undiluted    cows' 


THE  PROBLEM  OF  ARTIFICIAL  FEEDING  265 

milk.  Heubner  approached  the  subject  from  the  standpoint  of  tlie 
energy  required  by  the  infant,  and  suggested  mixtures  which  in 
proper  amounts  covered  the  number  of  calories  needed. 

In  practice  it  was  found  that  sometimes  milk  not  only  did  not 
agree,  but  at  times  caused  positive  injury.  Seeking  the  explanation 
for  this,  Biedert  suggested  that  the  protein  or  curd  was  at  fault. 
Later,  Czeruy  thought  the  trouble  was  due  to  the  fats,  especially  if 
given  in  too  great  quantities.  He  believed  that  the  large  quantities 
of  fat  used  up  too  much  of  the  alkali  in  the  intestine  in  saponifying 
it,  and  so  brought  about  a  condition  of  acidosis  and  of  gastro-intestinal 
disturbance.  Later,  Finkelstein  and  his  school  taught  that  the  sugars 
were  the  cause  of  the  trouble.  His  theories  are  considered  some- 
what more  fully  below.  Still  others  believe  that  the  difference  in 
the  character  and  amounts  of  the  inorganic  salts  are  responsible  for 
the  trouble  in  feeding.  The  bacteriologists  are  of  the  opinion  that 
bacteria  are  the  cause  of  the  trouble,  and  at  times  the  disturbance  is 
due  to  the  toxic  disturbances  which  the  bacteria  cause  to  be  formed 
in  the  milk.  Still  others  blame  the  difference  in  ferments  and  other 
specific  characters  of  the  milk,  claiming  that  these  specific  differences 
in  the  milk  of  various  animals  are  at  the  bottom  of  the  trouble. 
Again,  the  quantities,  the  hours,  and  methods  generally  have  been 
blamed.  Sometimes  one  of  these  things  is  the  cause  and  sometimes 
another. 

The  Problem  of  Artificial  Feeding. — This  subject  may  be  approached 
in  much  the  same  way  as  feeding  adults.  The  aim  of  such  feeding 
is  to  produce  a  healthy,  normally  developed  child  with  the  proper 
resistance  to  disease.  There  are  a  number  of  important  theoretic 
considerations  with  which  any  one  supervising  the  feeding  of  infants 
should  be  familiar,  but  it  should  always  be  borne  in  mind  that  the 
practical  clinical  result  is  to  be  the  final  criterion  and  not  the  theoretic 
standards. 

We  shall  consider  first  the  most  important  of  the  theoretic  con- 
siderations and  then  the  practical  infant  feeding.  The  reader  should 
first  read  the  sections  on  cow's  milk. 

The  Caloric  Needs  of  Infants. — The  total  caloric  needs  of  infants 
have  not  been  definitely  determined,  and  infant  feeding  can  be  done 
successfully  without  any  knowledge  of  calories.  However  true  this 
may  be,  the  study  of  infant  feeding  from  a  standpoint  of  the  caloric 
needs  adds  greatly  to  its  interest,  and  is  a  valuable  check  on  under- 
and  over-feeding.  It  must  be  borne  in  mind  that  the  food  must  not 
only  contain  the  requisite  number  of  calories,  but  it  must  be  digestible, 
absorbable,  and  capable  of  being  utilized  by  the  baby  without  causing 
any  untoward  sjrmptoms.  Finkelstein  observed  that  the  average 
breast-fed  infant  draws  daily  during  the  first  week  of  life  one-fifth 
of  its  body-weight ;  from  the  sixth  week  to  the  sixth  month,  one-sixth 
to  one-seventh,  and  during  the  latter  half  of  the  first  year,  one-eighth 


266  INFANT  FEEDING 

of  its  body-weight.  Expressed  in  round  numbers  per  kilo  of  body- 
weight,  during  the  first  three  months  it  receives  150  c.e.,  during  the 
second  period  somewhat  less,  and  during  the  third  period  120  to  130 
c.e.  Expressed  in  Heubner's  energy  quotient — that  is,  in  calories  per 
kilo  of  body-weight — the  requirement  during  the  first  three  months 
is  100  calories  per  kilo  (45.4  calories  per  pound),  during  the  second 
three  months  between  100  and  90  (40.9  calories  per  pound),  and 
during  the  latter  half  of  the  first  year  80  or  a  little  less  per  kilo 
(36.4  calories  per  pound).  Artificially  fed  children  are  supposed  by 
some  to  need  more  than  breast-fed  children  on  account  of  the  sup- 
posed greater  work  required  in  assimilating  cows'  milk.  Heubner 
suggests  120  calories  per  kilo.  The  other  figures,  however,  seem  to 
cover  the  needs  of  healthy  infants  as  demonstrated  in  practice.  The 
needs  of  older  children  have  been  given  under  Age  and  Food  Require- 
ments. 

The  requirements  vary  greatly  under  different  conditions.  Thus, 
an  infant  that  sleeps  a  great  deal  will  require  less  food  than  one  who 
is  wakeful,  and  the  high-strung,  nervous,  very  active  child  requires 
considerably  more  than  either.  The  reason  a  child  requires  so  much 
more  per  kilo  of  weight  than  an  adult  depends  largely  on  the  fact  that 
the  proportion  of  surface  is  greater  in  the  small  body.  A  certain 
amount  is  needed  for  growth,  as  it  has  been  variously  estimated  that 
from  9  to  15  per  cent,  of  the  food  taken  was  retained  for  the  purpose 
of  forming  new  tissue. 

Atrophic  children  and  those  under  weight  for  their  age  require 
more  per  kilo  than  the  normal  child.  Some  observers  have  fed  as 
high  as  170  calories  per  kilo  in  order  to  secure  a  proper  gain  in 
weight.  Such  feeding  should  only  be  done  when  under  very  careful 
supervision,  as  excessive  quantities  of  food  are  liable  to  cause  digestive 
disturbances. 

Caloric  Need  of  Premature  Infants. — Hess  and  others  have  studied 
this  question,  and  believe  that  premature  infants  require  more  food 
proportionately  than  the  full-term  baby.  The  need  varies  inversely 
with  age  and  birth  weight.  From  practical  observation  those  babies 
weighing  over  1500  grams  at  birth  require  from  100  to  132  calories 
per  kilo  of  body -weight;  those  weighing  under  1500  grams,  from 
115  to  170.  These  doubtless  vary  greatly,  and  such  high  caloric  feed- 
ing should  not  be  attempted  at  first,  but  the  amounts  should  be  small, 
and  increased  as  the  infant's  digestion  warrants  it.  The  milk  should 
not  be  given  until  after  the  first  bowel  movement.  Mothers'  milk 
only  should  be  used  for  these  infants,  and  every  effort  should  be  made 
to  secure  it.  The  first  day  Hess  suggests  diluting  the  breast  milk  with 
1  to  2  parts  of  water,  and  adding  sugar  to  make  up  for  this  dilution. 
Mothers '  milk  has  been  variously  estimated  at  from  650  to  700  calories 
per  liter,  or  about  22  calories  per  ounce.  About  30  calories  should  be 
given,  or  about  li/^  ounces  of  mothers'  milk  diluted  with  water.     If 


i 


DETERMIXATIOX  OF  THE  CALORIC  VALUE  267 

there  is  no  vomiting-  and  no  indigestion,  10  calories  a  day  may  be 
added — that  is,  about  Vii  ounce  of  mothers'  milk.  If  there  is  any 
digestive  disturbance,  the  increase  need  not  be  made  for  a  day  or 
two  or  more.  The  amount  of  fluid  to  be  given  may  be  estimated 
at  about  one-sixth  of  the  body- weight  a  day.  The  milk  may  be  diluted 
with  about  an  equal  quantity  of  water,  or  3  to  3i/2  per  cent,  sugar  of 
milk  solution,  and  the  remainder  of  the  water  given  between  feedings. 
After  ten  to  fifteen  days,  infants  under  1500  grams  should  be  held 
at  about  120  to  140  calories  per  kilo,  and  those  over  1500,  at  from 
110  to  130.  These  amounts  may  be  varied  with  the  condition  of  the 
.stools  and  the  weight.  The  milk  or  water  may  be  given  from  a  bottle 
by  means  of  the  Breck  feeder  or  by  using  a  catheter,  according  to  the 
vitality  of  the  infant.  Occasionally  the  breast  may  be  given  directly. 
The  great  probability  of  syphilis  in  foster  children  should  always  be 
borne  in  mind. 

Budin's  rule  as  to  the  quantity  of  milk  to  be  given  in  twenty-four 
hours  is  to  feed  one-fifth  the  body-weight,  or  multiply  the  body- 
weight  by  2  and  feed  one-tenth  that  amount.  Budin's  figures  are  a 
little  lower  than  Hess ',  owing  to  the  fact  that  he  used  650  calories  per 
liter,  while  Hess  estimates  700  calories  per  liter. 

The  Determination  of  the  Caloric  Value  of  Modified  Milk. — Moore- 
house  has  given  a  very  simple  method  for  estimating  the  caloric  value 
of  infants'  food  when  the  total  quantity  of  the  percentage  formula  is 
known.  The  method  is  as  follows :  Eeduce  the  twenty-four  hour 
amount  to  cubic  centimeters,  one  ounce  being  equal  to  29.5  e.c.  Next 
determine  the  number  of  grams  of  fat,  sugar,  and  protein  in  the  mix- 
ture by  multiplying  the  number  of  cubic  centimeters  and  the  daily 
amount  by  the  percentages  of  fat,"  sugar,  and  protein.  The  calories 
from  each  constituent  may  be  determined  by  remembering  that  a  gram 
of  fat  furnishes  9.3  calories,  and  a  gram  of  sugar  or  protein  furnishes 
4.1  calories.  The  calculation  ma}'  be  simplified  by  expressing  the 
arithmetical  process  by  equations,  thus:  Calories  from  fat  equal 
QxFx2.74;  calories  from  sugar  and  protein  equal  Qx(S  +  P)x 
1.21.  The  sum  of  these  two  values  gives  the  total  calories  furnished 
by  the  mixture,  and  this  figure  divided  by  the  weight  of  the  child  in 
pounds  gives  the  calories  per  pound  per  day.  In  the  above  formula 
Q  equals  the  twenty-four-hour  amount  in  ounces,  F,  S,  and  P  the 
percentages  of  fat,  sugar,  and  protein  expressed  as  whole  numbers; 
for  example,  1  per  cent,  equals  1  and  not  0.01. 

Fraley's  Method. — This  is  not  strictly  accurate,  but  sufficiently  so 
for  all  practical  purposes.  In  calculating  milk  mixtures  he  uses  the 
following  formula: 

( 2F  -f  P  +  S)  X  1:1  Q  =  Calories. 

or  twice  the  fat  percentage  plus  the  protein  percentage,  and  the  sugar 
percentage  multiplied  by  li/4  times  the  total  quantity  gives  approxi- 
mately the  number  of  calories.     For  example — 


268 


INFANT  FEEDING 


16  per  cent,  cream   2  ounces. 

Milk     14    .  ", 

Milk-sugar    1       " 

Diluent   to    32       " 

This  gives,  by  Bauer's  method,  fat  2.75,  protein  2,  and  sugar  5.1. 

Using  Fraley 's  formula,  5.5  +  2  +  5.1  =  12.6  X  40  =  504. 

Using  the  ordinary  calculations — 

2  ounces  cream   100  calories. 

14  ounces  milk    280       " 

1  ounce  milk-sugar    125       " 

505       " 
If  the  caloric  value  per  ounce  is  desired  the  Fraley  formula  may  be 
used  thus :  2F-fP+SXl^  =  Caloric  value  per  ounce. 

Holt  and  Howland  suggest  using  1%  instead  of  1^4  iii  this  formula. 
For  example,  woman's  milk  with  a  formula  of  4  per  cent,  fat,  2  per 
cent,  protein  and  7  per  cent,  sugar  would  yield  2X4-t-2-j-7  =  17 
X  1^4  =  21.25  calories  per  ounce. 

A  simpler  method  is  to  know  the  caloric  value  of  common  foods. 
Mothers'  milk  is  estimated  at  from  650  to  700  calories  per  liter,  or 
about  22  calories  per  ounce.     Cows'  milk  is  generally  estimated  at 
20  calories  per  ounce  for  market  (4  per  cent,  fat)  milk. 
Approximate  Caloric  Value  of  Different  Foods. 


Grams  of 

Calories 

Level  Table- 

Protein 

per  ounce. 

spoonfuls. 

Ijer  ounce. 

20 

0.56 

20 

0.90 

60 

0.70 

27.5 

0.90 

25.0 

0.90 

22.5 

0.90 

20.0 

0.90 

17.5 

0.90 

15.0 

0.90 

13.5 

0.96 

12.5 

0.96 

10 

0.96 

10 

0.28 

127 

3.50 

95 

2.50 

55 

127 

40 

120 

40 

120 

60 

120 

40 

80 

40 

109 

35 

107 

28 

115 

40 

120 

12.4 

7.5 

2.5 

1 

0.2 

6 

15 

245 

12 

2 

Woman's    milk    

Cows'   milk    

Cream    ( 20  per  cent. )    

7  per  cent,  milk    

6  per  cent,  milk   

5  per  cent,  milk    

4  per  cent,  milk    (whole  milk)    

3  per  cent,  milk 

2  per  cent,  milk   

1^  per  cent,  milk   (skimmed  milk)  . . 

1   per  cent,  milk    

Fat-free   milk    

Whey  

Sweetened  condensed  milk,  1  fl.  oz.   .  . 

Sweetened  condensed  milk,  1  oz 

Evaporated  milk   

Dried  milk    (Mammala)    

Milk-sugar    

Cane-sugar    

Dextrimaltose    

Malt  soup  e.xtract 

Barley  flour   

Wheat  flour   

Oat   flour    

Soy   flour    

Barley-gruel  ( 1  to  1 6  oz. )    

Barley-water  (1  tbsp.  to  16  oz.)    .... 
Albtimin- water  (white  1  egg  to  1  pt. ) 

Meat  juice    

Orange  juice    

Olive  oil    


PROTEiy  REQUIREMENTS  269 

Approximate  Measures. 

Milk-sugar    3  level  tablespoonfuls  =:  1  ounce  by  weight. 

Cane-sugar    2     '•  "  ^= 

Dextrimallose     .S     "  ■■  = 

Barlev  <ir  oat  flour ;i     "  '•  = 

Wheat  Hour    4     "  *•  =z 

Soy    Hour    3     "  "  ^ 

Budin's  Simple  Rule. — This  is  easily  remembered — one-tenth  the 
body-weight  in  twenty-four  hours.  If  the  body-weight  is  10  pounds, 
is  will  recjuire  1  pound  or  1  pint  of  milk  in  twenty-four  hours,  or 
from  114  to  ly^  ounces  of  milk  per  pound  of  body- weight.  This  is  a 
little  under  the  figure  given  above,  but  the  sugar,  generally  added, 
brings  it  up  to  the  required  amount. 

Protein  Requirements. — From  the  data  at  hand  it  is  not  possible 
to  state  what  is  the  best  amount  to  be  used  under  various  conditions. 
Howl  and  is  of  the  opinion  that  from  8  to  10  per  cent,  of  the  total 
calories  should  be  supplied  by  protein.  Talbot  states  that  the  average 
infant  re(|uires  1.5  grams  of  protein  per  kilogram  or  0.7  gram  per 
pound  of  body  weight,  while  many  require  at  least  2  grams  per 
kilogram  or  0.9  per  pound  and  some  2.5  grams  and  others  evidently 
even  more  than  this.  Inasmuch  as  cows'  milk  seems  to  be  somewhat 
deticient  in  certain  amino-acicls  necessary  for  growth  and  which  are 
supplied  by  the  protein  of  human  milk,  and  also  in  view  of  the  fact 
that  the  protein  of  cows'  milk  is  usually  well  digested  and  causes  no 
untoward  symptoms  even  if  given  in  excess,  it  is  well  to  be  on  the 
safe  side  and  give  rather  a  little  too  much  than  too  little.  One  and 
a  half  ounces  per  pound  of  body-weight  will  cover  the  nitrogen  needs 
of  the  average  baby.  The  dangers  of  feeding  too  little  protein  are 
anemia,  no  gain  in  weight,  or  too  small  a  gain,  and  a  lack  of  re-' 
sistanee.  Babies  fed  on  low  protein  diets  may  weigh  enough,  but 
are  not  as  strong  muscularly  nor  as  active  as  the  normal  infant.  Ex- 
cessive amounts  of  protein  usually  cause  constipation  with  large  stools 
and  high  protein  feeding  may  be  used  in  certain  diarrheal  disturb- 
ances. 

Fat  and  Carbohydrate  Requirements. — The  difference  in  the  food 
must,  of  course,  be  made  up  of  fat  and  carbohydrate.  The  best  re- 
sults are  obtained  by  using  both  fat  and  carbohydrates.  In  average 
healthy  infants  about  10  per  cent,  of  the  total  calories  requirement 
will  be  supplied  as  protein,  and  of  the  remaining  90  per  cent,  of  the 
calories  about  50  per  cent,  may  be  advantageously  given  as  fat  and 
the  remaining  40  per  cent,  as  carbohydrate. 

One  must  bear  in  mind  that  the  ultimate  aim  is  to  feed  the  baby 
successfully,  and  infant  feeding  should  not  be  regarded  in  the  light 
of  a  mathematic  game.  These  figures  are  based  on  successful  feeding 
carried  on  at  first  without  any  regard  for  calories.  The  expression 
of  results  in  calories  will,  however,  be  found  both  interesting  and 
useful.     To  avoid  repetition  the  remainder  of  this  subject  will  be 


270  INFANT  FEEDING 

considered  below  under  the  heading  of  Percentage  of  Fat  and  Carbo- 
hydrate. 

Mineral  Salts. — Of  late  these  have  come  in  for  considerable  atten- 
tion, and  many  disorders  of  nutrition  are  supposed  to  be  due  to  dis- 
turbances in  the  equilibrium  or  balance  of  the  various  mineral  con- 
stituents in  the  body.  At  present  our  knowledge  is  a  little  too  vague 
to  permit  any  very  definite  rules,  but  a  diet  low  in  inorganic  con- 
stituents should  not  be  given  a  growing  child.  It  seems  that,  just 
as  in  the  case  of  nitrogen,  balances  may  be  fixed  at  various  levels ; 
that  is,  if  the  diet  is  rich  in  salts  a  large  amount  is  excreted,  and  if  it 
is  poor  in  salts,  less.  Below  a  certain  level  it  is  not  well  to  go  (see 
Salts).  The  salts  are  important  in  building  up  the  tissues.  Calcium 
phosphate  and  magnesium  are  most  important. 

These  salts  are  present  in  sufficient  quantities  in  mothers'  milk  and 
in  cows'  milk.  In  modifying  cows'  milk,  reducing  the  protein  re- 
duces the  calcium  to  the  correct  amount ;  but  such  dilution  reduces 
the  magnesium  and  the  iron  below  the  normal  requirements. 

The  iron  in  the  food  given  most  infants  is  too  low;  but  the  ill 
effects  are  not  seen,  as  a  rule,  as  the  baby  starts  off  with  an  excess  of 
iron.  If  exclusive  milk  feeding  is  kept  up  too  long,  anemia  results, 
as  is  often  seen  in  infants  from  one  and  a  half  to  three  years.  Iron 
may  be  supplied  best  in  yolk  of  egg  or  in  meats,  or  it  may  be  given 
in  one  of  the  usual  forms.  Magnesium  may  be  supplied  by  using 
legume  flours  or  wheat  preparations.  Vegetable  broths  are  rich  in 
salts.  Lists  showing  the  salt-content  of  various  foods  will  be  found 
under  the  heading  of  Salts. 

Calories  and  Percentages. — There  has  been  a  great  deal  said  about 
the  caloric  method  of  feeding  and  the  percentage  method.  These  are 
not  methods  of  feeding,  but  methods  of  expressing  what  is  being 
done,  and  their  use  should  make  the  problem  more  clear.  The  caloric 
value  of  foods  is  important,  as  it  enables  one  to  estimate  whether  the 
baby  is  getting  insufficient  food  or  too  much  before  signs  of  actual 
trouble  occur.  The  percentage  method  of  dealing  with  the  subject 
is  valuable  because  it  gives  us  a  method  of  expressing  accurately  and 
concisely  what  the  baby  is  getting.  It  gives  us  a  basis  for  changing 
the  composition  of  the  food  to  suit  the  needs  of  the  individual  in- 
fant. 

Tolerance  for  Food. — The  success  or  failure  of  the  physician  will 
depend  largely  on  his  ability  to  adapt  food  to  the  digestive  capacity 
of  the  individual  infant.  One  might  say  that  every  baby  is  more  or 
less  like  every  other  baby.  For  infant  feeding  one  might  more  truth- 
fully state  that  every  baby  is  more  or  less  different.  The  differences 
are  not  always  apparent,  because  there  is  a  rather  wide  range  in  which 
the  average  baby  will  thrive.  That  is,  it  is  capable  of  growing  under 
more  or  less  adverse  circumstances,  and  of  utilizing  more  or  less  im- 
proper foods.     These  variations  have  definite  limits  in  both  direc- 


COMPOSITION  OF  MILE  271 

tions  as  regards  the  eoilipositiou  and  amount  of  foods.  Within  the 
limitations  the  baby  thrives;  if  the  limit  is  overstepped  the  infant 
becomes  ill.  Babies  living  in  the  country,  out  of  doors,  often  have 
wide  limits  of  tolerance.  The  dweller  in  the  over-heated,  under- 
ventilated  city  flat  usually  has  narrow  food  limitations.  Disease 
changes  the  tolerance  for  food  often  in  a  remarkable  way.  Foods 
of  a  composition  and  quantitj'  which  ordinarily  agree  very  well  may 
actually  cause  disease  when  given  in  certain  diseased  conditions.  Lac- 
tose, for  example,  in  normal  babies  is  assimilated  readily,  but  if  the 
intestine  becomes  damaged  it  may  be  the  cause  of  a  rather  definite 
disturbance  of  metabolism,  which  has  been  described  as  sugar-poison- 
ing. 

It  is  not  possible  to  modify  the  food  to  suit  all  the  differences  of 
metabolism  and  constitution.  We  cannot  always  tell  what  the  trouble 
is  when  we  know  there  is  something  wrong,  but  we  can,  by  keeping 
within  certain  limits,  prevent  much  trouble,  and  careful  study  and 
experiment  often  correct  existing  disturbances. 

The  Composition  of  Milk, — In  the  United  States  the  only  milk 
which  is  available  for  infant  feeding  is  that  from  the  cow.  To  insure 
success  in  infant  feeding,  one  should  know  its  composition,  how  it  com- 
pares to  mothers'  milk,  and  how  to  modify  it  to  suit  it  to  the  in- 
dividual infant. 

Comparison  of  mothers'  milk  and  cows'  milk: 

Average  Average 

woman  cow 

Protein    1.50  3.50 

Fat   3.50  4.00 

Sugar 7.00  4.50 

Salts    0.20  0.75 

Water    87.80  87.25 

100.00  100.00 

In  the  first  place  there  are  differences  which  are  not  apparent. 
Women's  milk  contains  ferments  which  stimulate  the  digestive  secre- 
tions in  the  child.  Those  of  cows'  milk  stimulate  the  digestion  of  the 
calf,  not  of  the  infant.  In  some  difficult  cases  even  a  small  amount 
of  women's  milk  will  be  found  of  great  service  in  stimulating  the 
digestion. 

The  Protein. — This  differs  both  in  amount  and  in  character.  In 
women's  milk  the  proteins  consist  of  lactalbumin  and  casein  in  the 
proportion  of  two-thirds  of  the  former  to  one-third  of  the  latter.  In 
cows'  milk  about  one-sixth  of  the  protein  is  lactalbumin  and  the  re- 
mainder casein.  The  total  protein  in  human  milk  precipitates  in  fine 
flakes,  that  of  cows'  milk  in  heavy  curds.  The  modification  of  the 
protein  consists  in  diluting  the  milk  until  the  protein  is  from  0.6  per 
cent,  or  more,  according  to  the  age,  size,  and  digestive  capacity  of  the 
infant.  In  some  cases  the  lactalbumin  and  curd  may  be  separated 
and  added  in  the  required  amounts. 

The  protein  may  be  prevented  from  forming  large  curds  by  the 


272  INFANT  FEEDING 

addition  of  lime-water,  sodium  citrate,  barley,  or  oatmeal-water. 
With  the  smaller  percentage  this  is  not  necessary. 

Sugar. — Milk-sugar  or  lactose  is  present  in  a  very  constant  propor- 
tion in  mothers'  milk — from  6  to  7  per  cent.  In  cows'  milk  the  sugar 
averages  about  4.50  per  cent.  Diluting  cows'  milk  reduces  the  sugar 
still  farther,  so  that  sugar  must  be  added  to  make  up  the  percentage. 
This  is  not  added  to  sweeten  the  milk,  but  to  increase  its  food  value. 
During  the  first  few  days  of  life  sugar  may  be  given  in  the  propor- 
tion of  5.0  to  5.5  per  cent. ;  from  the  second  week  to  the  third  month, 
6  per  cent. :  and  from  that  time  up  to  the  eleventh  month,  7  per  cent. 
may  be  used.  At  the  eleventh  month  it  may  be  reduced  to  5,  and  a 
little  later  omitted  altogether,  unless  the  child  is  under  weight. 
These  are  safe  limits,  both  from  the  standpoint  of  nutrition  and 
tolerance.  Some  infants  will  tolerate  more  than  7  per  cent.,  but  there 
is  no  advantage  in  giving  more,  and  it  may  give  rise  to  symptoms  of 
sugar-poisoning. 

There  has  been  a  great  deal  of  discussion  about  the  kind  of  sugar  to 
be  used.  Lactose,  the  sugar  found  in  milk,  is  best  for  normal  infants. 
It  may  be  given  in  sufficient  amounts  more  easily  than  the  other 
sugars,  as  it  is  not  so  sweet.  Care  should  be  taken  to  get  a  pure  sugar. 
Milk-sugar  may  cause  trouble  if  there  is  digestive  disturbance,  even  in 
the  amounts  mentioned  above,  and  one  of  the  other  sugars  or  other 
carbohydrate  (as  starch)  may  then  be  substituted.  In  the  severe 
diarrheas  the  starch  foods  (as  barley  or  rice  gruel)  are  better  borne. 

Cane-sugar  is  cheaper  and  often  substituted  for  lactose  in  ordinary 
feeding,  but  it  is  so  sweet  that  only  about  half  as  much  can  be  used. 
In  some  cases  it  is  apparently  digested  better  than  lactose. 

Maltose  is  much  used  at  present  in  place  of  the  above.  It  is  gen- 
erally given  in  mixtures  containing  dextrose  as  well.  If  maltose  is 
used,  it  should  be  begun  in  small  quantities  and  increased  to  the 
desired  quantity,  as  it  sometimes  causes  diarrhea  and  other  disturb- 
ances, particularly  if  any  gastro-intestinal  trouble  exists.  In  such 
cases  it  should  be  used  with  great  care.  It  ferments  very  easily.  It 
has  the  advantage  of  being  readily  assimilated,  as  is  especiallj'  in- 
dicated in  loss  of  weight  or  stationary  weight  without  apparent  cause. 

The  following  is  said  to  be  the  composition  of  some  of  the  most 
frequently  used  preparations  containing  them  : 

Maltose.  Dextrose. 

^xlet's    Nahrzucker    *.  .  .  .  52.44  41.21 

Loefland's  Nahrzucker   40  60 

Dextro-maltose     51  47 

Neutral  maltose    (Maltzyme  Co.)     63.66  8.9 

Loefland's  malt  soup 58.91  15.42 

Borchardt's  malt  soup   57.51  15.76 

Other  analyses  of  infants'  foods  containing  maltose  and  dextrose 
will  be  found  under  the  heading  of  Proprietary  Foods. 

Glucose  solutions  are  sometimes  used  by  the  drop  method  by  rectum, 
either  with  or  without  salt  solution.     (See  Rectal  Feeding.) 


I 


CALCULATIOX  OF  PERCENTAGES  273 

The  subject  of  the  different  sugars  in  relation  to  the  various  in- 
testinal disturbances  needs  further  study.  (See  also  Fiukelstein '.s 
theories. ) 

Fat.— The  fat  of  human  milk  averages  4  per  cent.;  that  of  cows' 
milk  is  the  same.  When  the  milk  has  been  diluted,  the  amount  must 
either  be  made  up  by  adding  cream  or  by  using  the  upper  one-third  or 
upper  half  of  the  milk  after  the  cream  has  risen.  Gravity  cream 
contains  about  twice  as  many  bacteria  as  centrifugal  cream,  and  the 
objections  formerly  urged  against  the  latter  appear  to  be  unfounded. 

The  amount  of  fat  to  be  given  varies  with  the  age,  weight,  and 
digestive  ability  of  the  infant.  For  an  average  infant,  2  per  cent, 
the  first  week,  2.5  per  cent,  the  second,  and  3  per  cent,  the  third  week 
are  the  amounts  usually  prescribed.  In  using  whole  milk  mixtures 
the  amount  of  fat  is  low,  and  as  fat  is  most  frequently  the  stumbling 
block  in  digestion,  these  mixtures  are  easier  to  adapt  to  the  infant's 
digestion.  If  the  child  is  under  observation  there  is  no  objection  to 
raising  the  fat  to  4  per  cent,  at  about  the  fourth  month,  after  that 
time  this  amount  must  not  be  exceeded,  or  the  infant  is  apt  to  develop 
indigestion,  with  the  large  whitish  stools  giving  off  the  characteristic 
odor  of  the  fatty  acids. 

The  Calculation  of  Percentages  in  Milk  Mixtures. — This  is 
needed  if  one  thinks  in  percentages,  and  a  simple  rule  is  given  by  Holt 
as  follows :  To  determine  the  percentage  of  any  constituent  in  the 
food,  multiply  its  percentage  in  the  original  milk,  cream,  or  milk  by 
the  number  of  ounces  of  each  in  the  food,  and  divide  by  the  total  num- 
ber of  ounces  of  food  prepared. 

For  example,  a  40-ounce  mixture,  made  up  of  20  ounces  of  the 
upper  half  of  market  (4  per  cent.)  milk;  that  is,  of  7  per  cent,  milk, 
20  ounces  of  water,  and  li/'o  ounces  milk-sugar: 

7  X  20  =  140  represents  fat  in  mixture, 
140  -^  40  =:  3.5  percentage. 

The  protein  in  7  per  cent,  milk  is  about  3.50  per  cent. : 

3.50  X  20  =:  70  represents  protein  in  mixture, 
70-^40^1.75  percentage  of  protein. 

The  sugar  in  a  7  per  cent,  milk  is  about  4.50  per  cent. : 

4.50  X  20  ^  90  represents  sugar  in  milk, 
90  -;-  40  z=  2.25  percentage  of  sugar  in  milk. 

11/^  ounces  of  milk-.sugar  in  20  ounces  adds  about  3.75   (1.5  ^40  = 
0.0"375).     The  total  sugar  is  2.25  +  3.75  =  6  per  cent. 

The  Use  of  Alkalis. — Having  considered  the  caloric  needs  of  in- 
fants and  the  percentages  of  food  constituents  ordinarily  employed, 
we  may  take  up  briefly  some  of  the  reasons  for  modifying  milk  with 
reference  to  the  digestion  of  the  infant.  It  should  be  borne  in  mind 
that  the  gastro-intestinal  tract  of  the  infant  is  not  like  that  of  an  adult. 
18 


274  INFANT  FEEDING 

At  birth  the  digestive  capacity  is  small,  and  it  increases  as  the  child 
grows,  providing  proper  food  is  given.  The  steps  in  the  digestion  of 
milk  are,  first,  the  rennet  changes  the  calcium  casein  of  the  milk  intq 
paracasein  (curd),  which  is  not  affected  by  pepsin.  Then  the  acid  of 
the  stomach  unites  with  the  lime  of  the  paracasein,  forming  a  free 
paracasein  curd,  which  is  more  dense  than  the  paracasein,  but  which 
is  capable  of  being  digested  by  pepsin.  This  free  paracasein  curd 
acts  like  a  base  and  unites  with  the  acid,  forming  a  paracasein  chlorid, 
which  is  also  digestible  by  pepsin.  If  milk  is  diluted  with  plain 
water,  the  rennet  acts  promptly  and  the  clotting  occurs  in  a  normal 
manner.  AVomen's  milk  clots  in  small  curds,  but  cows'  milk  in  large 
dense  ones,  so  that  alkalis  are  often  added  for  the  purpose  of  checking 
or  altering  the  curd  formation.  The  most  used  substances  are  lime 
water  and  sodium  bicarbonate.  Lime-water  is  freely  alkaline  and 
makes  the  clotting  take  place  more  slowly,  alters  the  form  of  the  curd, 
making  it  looser,  and  probably  a  certain  amount  of  the  milk  passes 
into  the  intestine  without  having  been  much  changed  in  the  stomach. 
When  sodium  bicarbonate  is  used,  its  greater  alkaline  properties 
prevent  not  only  the  action  of  the  rennet,  but  the  pepsin  and  acid  as 

Table  I. — Alkalinity  Required  by  Theory. 


Milk  rendered 

alkaline  before 

dilution. 

Water. 

Alkaline 
food. 

Lime-water  to 
each  oz.  food. 

Grains  bicarb. 

soda  to  each 

oz.  food. 

1  oz. 

+ 

19  oz. 

= 

20  oz. 

.25  per  cent. 

or 

1 

grain. 

2  " 

+ 

18  " 

= 

20  " 

•50 

or 

^\ 

u 

3  « 

+ 

17  " 

= 

20  " 

.75 

or 

/<J 

l< 

4  " 

+ 

16  " 

= 

20  " 

1.00 

or 

.% 

« 

5  " 

+ 

15  " 

=: 

20  " 

1.25 

or 

^'^ 

l( 

6  " 

+ 

14  " 

= 

20  " 

1.50 

or 

2% 

<( 

7  " 

+ 

13  " 



20  '^ 

1.75 

or 

V 
20 

« 

8  " 

+ 

12  " 

= 

20  " 

2.00 

or 

is 

« 

9  " 

+ 

11  " 

^ 

20  " 

2.25 

or 

9 

« 

10  " 

+ 

10  " 

= 

20  " 

2.50 

or 

iS 

(( 

20  " 

+ 

— 

20  " 

5.00 

or 

1 

« 

well,  until  the  alkali  is  neutralized.  This  probably  causes  gastric 
digestion  to  be  small  in  amount  and  the  work  falls  on  the  intestine. 
It  is  thought  that  fluid  milk  passes  rapidly  into  the  intestine,  whereas 
if  it  clots  it  remains  until  digested.  It  has  been  estimated  that  add- 
ing 5  per  cent,  lime-water  to  milk  will  render  it  alkaline,  whereas 
20  per  cent,  will  check  the  digestion  of  protein  in  the  stomach  entirely. 
With  sodium  bicarbonate  1  grain  to  the  ounce  renders  the  milk 
alkaline,  2  grains  to  the  ounce  facilitates  the  gastric  digestion  of  pro- 
tein by  changing  the  character  of  the  curd,  while  8  grains  to  the 
ounce  will  suspend  the  gastric  digestion  of  protein. 

As  generally  practised,  5  per  cent,  of  lime-water  is  added  to  a  milk 
mixture,  regardless  of  the  actual  amount  of  milk  in  the  mixture. 
When  the  mixture  is  a  weak  one  the  eflPect  is  very  marked,  as  there 
is  but  little  milk  to  be  affected,  but  in  the  stronger  mixtures  the  effect 
is  less  marked. 


THE  USE  OF  ALKALIS  275 

The  tables  prepared  by  Southworth  are  interesting  in  this  connec- 
tion. 

Taking  the  20-ounce  mixture  as  an  illustration,  if  the  milk  to  be 
used  is  first  rendered  alkaline  by  the  addition  of  5  per  cent,  lime- 
water  or  1  grain  of  sodium  bicarbonate  to  each  ounce  of  milk,  and 
this  is  diluted  to  make  the  feeding  mixture,  the  table  on  page  274  will 
show  how  much  lime-water  or  sodium  bicarbonate  each  ounce  of  the 
food  mixture  would  contain. 

It  is  instructive  in  this  connection  to  compare  the  actual  results 
obtained  in  the  method  usually  practised : 

Table  II, — Alkalinity  Obtained  in  Practice. 


Water. 

Milk. 

Lime- 
water 

Bicarb, 
soda. 

Food. 

Per  cent,  lime- 
water  to  milk. 

Grs.  bicarb. 

soda  to  each 

oz.  milk. 

18  or. 

+ 

1  oz. 

+ 

1   OZ. 

or 

20 

grs. 

= 

20  oz. 

100  per  cent. 

20  grains. 

17  " 

+ 

2  " 

+ 

or 

20 

= 

20  " 

50 

(( 

10 

16  " 

+ 

3  " 

+ 

or 

20 

= 

20  " 

33i 

« 

6* 

15  " 

+ 

4  " 

+ 

or 

20 

= 

20  " 

25 

« 

5 

14  " 

+ 

5  " 

+ 

or 

20 

= 

20  " 

20 

<i 

4 

13  " 

+ 

6  " 

+ 

or 

20 

= 

20  " 

161 

i( 

3^ 
3 

12  " 

+ 

7  " 

+ 

or 

20 

^ 

20  " 

14 

(1 

11  " 

+ 

8  " 

+ 

or 

20 

= 

20  " 

12} 

(1 

2i 

10  " 

+ 

9  " 

+ 

or 

20 

=r 

20  " 

11 

« 

2 

19  " 

4- 

or 

20 

= 

20  " 

5 

<( 

1 

In  3"0ung  infants  and  in  those  with  feeble  digestions  the  use  of 
alkalis  is  a  great  help.  We  rarely  use  over  1  ounce  of  lime-water  in 
20-ounee  mixtures  for  healthy  infants.  Theoretically  and  practically 
lime-water  is  the  best  and  safest.  Milk  to  which  lime-water  is  added 
should  not  be  boiled,  as  the  lime  is  precipitated  at  the  higher  tem- 
peratures. 

Other  alkalis  may  be  used,  as  syrup  of  lime  or  magnesia.  Potas- 
sium carbonate  has  been  suggested.  The  continued  use  of  strong 
alkalis  is  not  to  be  commended,  as  it  retards  development. 

The  clotting  may  be  changed  mechanically  by  adding  a  gruel  made 
of  barley  flour  or  other  cereals.  It  is  sometimes  an  advantage  to 
dextrinize  the  gruel  to  render  it  more  digestible. 

Boiling  milk  is  sometimes  practised  in  order  to  change  the  curd. 
Boiled  milk  is  often  useful  where  there  is  a  tendency  to  frequent 
stools.     In  some  children  it  produces  marked  constipation. 

Acid  milk,  as  buttermilk  or  kumiss  and  similar  preparations,  are 
often  used  when  ordinary  milk  mixtures  are  not  well  borne.  The 
protein  is  precipitated  in  fine  curds  and  is  easily  digested,  as  the 
digestive  juices  can  affect  it  easily  and  the  rennet  does  not  cause 
further  clotting. 

Still  another  method  of  getting  at  the  question  of  large  curds  is  by 
adding  sodium  citrate  to  the  milk.  From  1  to  3  grams  to  each  ounce 
of  milk  in  the  mixture  may  be  used.  The  soda  forms  a  compound 
with  the  casein,  and  the  citric  acid  unites  with  the  calcium,  fonning 


276  INFANT  FEEDING 

calcium  citrate.  This  prevents  clotting,  and  we  have  found  this 
useful  in  giving-  the  higher  percentages  of  protein  to  children  with 
weak  digestions,  and  also  in  infants  who  are  troubled  with  mild  forms 
of  constipation. 

Practical  Infant  Feeding. — Having  considered  the  more  important 
principles  on  which  infant  feeding  is  based,  we  are  in  a  position  to 
consider  it  practically. 

Pure  Milk  Essential. — It  should  be  borne  in  mind  that  pure,  clean 
milk  is  essential  to  infant  feeding.  This  has  been  considered  in  the 
article  on  Milk.  The  person  caring  for  the  child  should  be  carefully 
instructed  on  this  point,  and  the  milk  selected  should  be  the  best 
obtainable.  It  is  always  cheapest  in  the  end.  Careful  instruction 
should  also  be  given  about  keeping  the  milk  cold,  about  sterilizing 
the  bottles  and  all  the  utensils  that  are  used  in  the  preparation  of 
the  baby's  milk,  so  as  to  avoid  contaminating  it.  If  very  pure  milk 
is  obtainable,  it  may  be  used  raw,  if  there  is  any  doubt,  it  should  be 
pasteurized  (see  Milk),  and  if  it  is  very  doubtful,  it  should  be  steril- 
ized by  boiling.  We  do  not  believe  that  milk  that  needs  boiling 
(unless  to  keep  it  in  the  absence  of  ice)  is  fit  for  infant  feeding;  but 
in  spite  of  all  that  can  be  done  some  people  will  use  it. 

It  is  a  good  plan  to  test  the  milk  occasionally  to  ascertain  the  fat- 
content. 

The  directions  for  preparing  the  food  should  be  written  out,  show- 
ing the  quantity  of  each  ingredient,  the  number  and  size  of  feeding, 
etc.  Always  make  certain  that  the  directions  are  clearly  under- 
stood. 

Bottled  Milk  and  Bacteria. — Hess  has  found  that  the  bacteria  are 
far  more  numerous  in  the  upper  layers  of  the  cream,  and  that  they 
become  gradually  fewer  in  its  lower  portion.  The  upper  2  ounces  of 
the  cream  contain  the  greatest  number  of  bacteria,  and  this  is  true  of 
the  tubercle  bacilli,  as  well  as  of  the  streptococci  and  other  bacteria. 
He  suggests  that  in  place  of  using  the  upper  cream,  as  ordinarily 
practised,  it  is  better  to  discard  the  upper  two  ounces.  The  average 
bottle  of  such  partially  skimmed  milk  contains  2  per  cent,  of  fat  and 
3.5  per  cent,  of  protein.  The  top  7  ounces  of  what  remains  in  the 
bottle  contain  12  per  cent,  of  fat,  8  ounces  of  10  per  cent,  fat,  and  12 
ounces  of  7  per  cent.  fat.  These  portions  of  the  milk  may  be  used  in 
the  ordinary  percentage  mixtures. 

Substitutes  for  Milk. — If  pure  milk  cannot  be  obtained,  we  prefer 
temporary  feeding  with  condensed  milk  mixtures,  malted  milk,  dried 
milk,  or  sometimes  buttermilk.  When  the  former  are  used  it  is 
always  wise  to  give  the  baby  a  few  teaspoonfuls  of  orange-juice  daily, 
or  every  other  daj^,  to  prevent  scurvy.  If  the  above  foods  are  to  be 
used  for  any  length  of  time,  fat  should  be  supplied,  and  if  pure 
cream  cannot  be  obtained,  olive  oil  may  be  used. 

The  Interval  for  Feeding. — The  schedule  for  feeding  is  given  under 


THE  QUANTITY  277 

Maternal  Nursing  and  also  the  Laboratory  Method.  There  is  a  wide 
difference  of  opinion  concerning  the  proper  interval.  At  present  the 
swing  of  the  pendulum  is  to  very  long  intervals.  It  depends  on  the 
individual  baby.  The  interval  and  the  size  of  the  feeding  are  closely 
related.  The  amount  of  food  needed  in  twenty-four  hours  should  be 
divided  into  the  number  decided  upon  according  to  the  size  of  the 
feeding,  and  that  is  settled  by  the  age  and  size  of  the  baby.  Normal 
babies  may  be  given  the  food  every  three  hours  during  the  first  month. 
Two  hours  or  two  hours  and  a  half  feeding  may  be  used  in  small  or 
premature  babies.  Four-hour  intervals  may  be  used  if  very  strong 
milk  mixtures  are  used  or  in  feeding  undiluted  milk.  Long  intervals 
are  also  useful  in  atony  of  the  stomach  and  when  the  gastric  digestion 
is  weak.  In  infants  who  are  very  small  the  interval  may  be  shorter, 
and  during  illness,  when  only  a  spoonful  or  two  of  food  can  be  given 
at  a  time,  the  interval  may  also  be  shortened.  Regular  feeding  is 
very  important.  During  the  day  the  baby  should  be  fed  on  schedule 
whether  it  is  awake  or  not,  as  it  will  otherwise  wake  at  night  for  the 
bottle  it  has  missed.  Night  feeding  should  be  omitted  as  early  as 
possible.  If  sufficient  food  is  given  during  the  day,  the  baby  may 
be  allowed  to  sleep  all  night  if  it  will.  Normal  babies  do  not  need 
the  night  feeding  after  the  fifth  month,  and  it  can  often  be  dispensed 
with  after  the  third.  Small  babies  and  atrophic  ones  need  the  full 
.  number  of  feedings,  as  they  require  more  milk  to  make  them  gain. 

The  Quantity. — The  total  quantity  of  mixture  to  be  given  depends 
on  the  size  and  age.  The  normal  infant  requires  about  3  ounces  of 
fluid  per  pound  of  weight  during  the  first  i  months  and  about  2i/2 
ounces  per  pound  later  and  in  late  infancy  2  ounces  per  pound. 
As  a  general  thing  we  increase  the  strength  of  the  mixture,  the  quan- 
tity alternately,  but  there  are  exceptions  to  this.  The  size  of  each 
feeding  will  depend  on  the  baby.  Babies  of  average  weight  for  their 
size  may  usually  be  given  the  following  sized  feedings: 

Birth    7i  3288  3  88 

1  month 8*       385.5       3         88 

2  months 10*       4762       4        118 

3  •'                 12i  5670  5  147 

4  «                 U'  6350  6  177 

5  «  ; 15  6704  7  206 

6  "         16  7257  8  236 

7  "                17  7711  8  236 

8  "  "       171  8051  8  236 

9  "  "          ...  18*  8391  S  236 

10  "  .  . .  19|       8958       8        236 

11  «  ...  20^       9185       8        236 

12  «    21        9525       9        265 

The  above  figures  are  approximate,  and  may  usually  be  exceeded 
by  i/o  or  1  ounce  after  the  third  month  in  normal  babies,  and  much 


278  INFANT  FEEDING 

more  in  atrophic  infants.     Babies  ahead  of  the  schedule  in  weight 
require  correspondingly  large  feedings. 

The  following  figures  of  Ladd  are  of  great  interest,  as  they  show 
how  the  atrophic  baby  needs  more  food  before  it  will  gain  in  weight : 

Atrophic   infants,   corre- 
Normal  average  infant  Pounds         Ounces       spending  weights    re- 

weighing  at  rounas.        uunces.      ^ej^ed  on  an  average. 

Ounces. 

1  week  6  receive  1  3^ 

1   "   7  "  2  4 

3  weeks  . '. 8  "  2*  4i 

5   "   9  "  3  4i 

7  "    10  "  3  5i 

9   "   11  "  3i  5i 

3  months 12  "  4  6i 

3*   "    13  "  4i  7 

4:1       "  -14  "  44  6 

5  "    15  "  5i  6 

6  "    16  "  6  6i 

8  "    17  "  7  7 

9  "    18  "  8  7i 

10  "  m  "  8  7i 

11  "  20  "  8  7 

12  "  21  "  9  7i 

13  "  22  "  9  8 

The  regulation  of  the  size  of  the  feeding  is  important.  The  stom- 
ach is  an  elastic  bag,  and  what  might  be  regarded  as  a  normal  capacity 
varies  within  certain  limits.  If  too  much  is  given  at  a  feeding,  some 
of  it  will  be  regurgitated  soon  after.     (See  Vomiting.) 

When  this  is  the  case,  the  size  of  the  feeding  should  be  reduced. 
Infants  improperly  fed  are  usually  hungry  all  the  time,  and  take 
readily  almost  any  amount,  merely  to  regurgitate  it  soon  after.  It  is 
a  common  mistake  to  give  these  babies  too  large  feedings.  Only  as 
much  as  can  be  retained  should  be  given.  These  babies  usually  have 
atonic  stomachs  from  taking  feedings  that  are  too  large.  At  first  the 
feedings  in  these  cases  should  be  small  and  the  interval  long. 
Strychnin  in  proper  doses  is  of  great  value  in  these  infants.  The 
size  of  the  feeding  and  the  interval  should  be  approached  to  the 
normal  average  as  rapidly  as  possible,  but  the  individual  require- 
ments should  never  be  lost  sight  of. 

Ssnitkin,  of  St.  Petersburg,  has  estimated  the  amount  to  be  fed  to 
a  child  according  to  the  weight.  He  ascertained  that  a  baby's  stom- 
ach held  about  one-hundredth  of  its  weight  at  birth,  and  that  the 
increase  amounted  to  about  a  gram  a  day.  By  taking  one-hundredth 
of  the  initial  weight  at  birth  and  adding  a  gram  for  each  day  the 
average  amount  required  for  each  feeding  is  ascertained.  This  is  a 
fair  working  rule,  but  practically  the  amount  is  easily  determined  by 
the  methods  already  described. 

Beginning  Bottle  Feeding. — When  the  baby  is  weaned  it  should 
be  done  gradually  if  possible,  as  this  gives  the  digestive  organs  an 


MILK  MODIFICATION  279 

opportunity  to  become  accustomed  to  the  new  milk  gradually.  The 
digestive  juices  are  secreted  as  needed,  and  the  stimulus  comes  from 
the  food.  Sometimes,  if  an  entirely  different  food  is  substituted 
suddenly,  the  digestive  juices  are  not  equal  to  the  demand  and  in- 
digestion results. 

To  avoid  this,  all  the  food  elements  should  be  begun  very  low. 
The  first  day  half  the  required  strength,  the  second  day  somewhat 
stronger,  and  so  on  each  day  until  the  proper  food  is  reached.  Some 
babies  will  take  only  a  day  or  two  to  make  the  change,  others  will 
require  a  week  or  more. 

The  aim  should  be  to  produce  a  firm,  healthy  looking  baby,  and  not 
a  fat,  flabby  one.  The  foods  should  be  increased  as  indicated,  keep- 
ing in  mind  the  presence  or  absence  of  vomiting,  the  number  and 
character  of  the  stools,  the  gain  in  weight,  and  the  general  appear- 
ance. A  baby  that  does  not  look  well  and  contented  has  something 
that  needs  correction.  It  may  be  in  the  food  or  in  the  general  sur- 
roundings or  care. 

If  the  baby  is  getting  along  well,  it  gains  in  weight  following  ap- 
proximately the  normal  weight  curve.  It  sleeps  well,  and  is  happy 
and  looks  contented.  The  stools  are  normal  and  there  is  no  vomiting. 
If  the  baby  is  not  doing  well,  the  picture  is  just  the  reverse.  There 
is  little  or  no  gain,  and  the  child  looks  pale  or  flabby  and  unhappy. 
There  is  usually  fretting,  crying,  restless,  disturbed  sleep,  often 
vomiting,  and  bad  stools. 

MILK  MODIFICATION 
METHODS  OF  PRACTICAL  VALUE  IN  MODIFYING  MILK 

After  obtaining  a  careful  history  of  the  child  and  its  family  in 
order  to  estimate  the  effect  of  possible  inherited  diseases  and  of  the 
previous  foods  used  and  a  careful  physical  examination  to  determine 
the  presence  or  absence  of  diseases,  the  food  formula  may  be  thought 
out.  The  age,  the  size,  the  general  appearance,  the  condition  of  the 
digestive  tract,  the  nature  of  the  stools,  all  play  a  part  in  the  de- 
cision. If  the  child  has  not  been  gaining  or  is  upset  it  is  well  to 
avoid  making  the  errors  in  diet  responsible  for  the  trouble. 

First,  determine  the  number  of  feedings,  usually  six,  but  variations 
between  four  and  ten  may  be  used.  Next,  fix  upon  the  total  quantity 
based  on  the  rule  of  three  ounces  per  pound  during  the  first  four 
months,  two  and  a  half  later,  and  two  in  late  infancy.  The  total 
quantity  should  not  exceed  forty-eight  ounces  during  the  first  year 
and  many  pediatrists  set  the  limit  at  forty-two.  The  total  quantity 
divided  by  the  number  of  feedings  gives  the  size  of  each  feeding. 
This  will  fall  close  to  one  ounce  more  than  the  baby's  age  in  months 
and  should  rarely  exceed  eight  ounces.     If  the  baby  gets  too  much 


280  INFANT  FEEDING 

at  one  feeding  it  will  regurgitate  it  within  five  or  ten  minutes.  This 
may  also  be  caused  by  moving  the  baby  about  after  feeding  or  from 
the  baby's  taking  the  milk  too  rapidly.  Marantic  babies  take  large 
feedings,  but  part  of  the  milk  passes  almost  directly  into  the  in- 
testine, and  care  should  be  taken  not  to  dilate  the  stomach  of  a  weak 
infant  by  too  large  feedings. 

It  is  a  rather  general  custom  to  start  the  feeding  with  cows'  milk, 
and  what  has  been  said  under  the  caption  of  Beginning  Bottle  Feed- 
ing should  be  borne  in  mind.  A  simple  rule  is  to  give  the  child 
twice  as  many  ounces  of  milk  as  it  weighs  in  pounds  for  the  smaller 
ones,  and  an  ounce  and  a  half  per  pound  for  the  larger  ones.  A 
better  plan  is  to  estimate  the  caloric  needs  of  the  infant  (see  Caloric 
Needs  of  Infants).  This  is  done  by  multiplying  the  weight  in  pounds 
by  45  for  children  under  three  months,  by  40  for  children  between 
three  and  six  months,  and  by  36  between  six  and  twelve  months. 
If  the  child  is  under  weight  or  very  active  it  may  require  more  and 
premature  or  very  small  sized  infants  may  require  50,  60  or  even  70 
calories  per  pound. 

The  first  thought  is  sufficient  protein  and  one  and  a  half  ounces 
of  cows'  milk  per  pound  will  ordinarily  supply  the  required  amount. 
For  example,  a  child  of  fifteen  pounds  ordinarily  would  require  15 
times  40  or  600  calories.  An  ounce  and  a  half  of  milk  for  each 
pound  would  be  twenty-two  and  a  half  ounces,  which  at  20  calories 
per  ounce  would  be  450  calories,  leaving  150  to  be  supplied  by  the 
addition  of  some  other  food.  Sugar  is  added  up  to  5  per  cent,  of 
the  total  quantity  of  food  to  make  up  the  difference  needed.  An 
ounce  of  sugar  (2  level  tablespoonfuls  if  cane  sugar,  or  3  if  milk 
sugar  or  dextrimaltose)  will  furnish  120  calories  and  an  ounce  and 
a  quarter  would  make  up  the  required  quantity.  The  formula  would 
then  be 

Whole  milk  23  ounces 

Boiled  water  13  oimces 

Milk  sugar  3%  level  tablespoonfuls 

This  formula  would  not  be  suited  to  start  with  if  the  child  had  not 
been  taking  cow's  milk,  but  similar  ones  much  weaker  should  be 
used  based  on  35  calories  per  pound  or  even  less  for  a  few  days  until 
the  infant's  digestion  becomes  accustomed  to  the  new  food,  when  it 
may  be  increased  to  the  required  amount.  The  child  should  not  be 
kept  on  the  low  value  foods  too  long.  In  this  way  a  formula  may  be 
worked  out  as  a  starting  point,  and  as  the  factor  of  safety  of  the 
nutrition  of  the  average  healthy  baby  is  a  wide  one,  most  infants 
will  thrive  on  such  mixtures. 

Holt  and  Howland  have  arranged  the  following  table  of  whole 
milk  mixtures.  If  more  than  20  ounces  is  required  the  calculations 
are  easily  made.  The  ages  are  only  suggestions  and  are  not  to  be 
followed  closely. 


MU.K   MODIFICATION 


281 


Formulas  from  Whole    (4  per  cent.)    Milk 
Giving  Approximate  Percentage  Composition  and  Caloric  Value 


Milk  (ounces)  .  .  . 
Water  (ounces)  . 
Gruel  1  (ounces) 
Sugar  2 

(even    tbsp.)  . . 

Total     

Fat.  per  cent. .  . . 
Sugar,  per  cent.. 
Starch,  per  cent. 
Protein,  per  cent. 
Calories  per  oz. . . 
Approx.    age 

indication 


I 

II 

Ill 

IV 

V 

VI 

VII 

VIII 

IX 

0 

7 

8 

9 

10 

11 

12 

13 

14 

14 

13 

12 

11 

10 

9 

7 

1 

5 
2 

1 
5 

2* 

2i 

2i 

2A 

2i 

2i 

2 

li 

i 

20 

20 

20 

2'0* 

20 

20 

20 

20 

20 

1.20 

1.40 

1.60 

1.80 

2.00 

2.20 

2.40 

2.60 

2.80 

5.70 

6.00 
.... 

6.00 

6.50 

6.50 

6.50 

6.00 
.40 

5.50 

.80 

5.50 
2.00 

V.66 

1.20 

!l.40 

V.eo 

V.75 

V.96 

2.10 

2.25 

2.40 

11.5 

12.5 

13.5 

14.5 

15.5 

16.5 

17.0 

18.0 

20.0 

•>  da. 

1  wk. 

3  wk. 

2  mo. 

3  mo. 

4  mo. 

5  mo. 

6  mo. 

8  mo. 

X 

IJ 

0 
5 

1 
20 
3.00 
5.00 
2.00 
2.60 
21.0 
9-U 
mo. 


If  the  child  does  not  gain  in  weight  it  may  be  tried  on  skim  milk 
mixtures  with  high  sugar  content.  This  increases  the  protein  and 
lessens  the  fat,  which  seems  so  often  to  be  the  stumbling  block  in 
bottle  feeding.  It  also  furnishes  much  of  the  energy  in  the  most 
easily  utilized  form  as  well  as  a  high  percentage  of  salts  which  aid 
in  water  retention.  The  milk  can  have  all  the  gravity  cream  re- 
moved, the  remainder  furnishing  10  calories  per  ounce  and  contains 
about  1  per  cent,  of  fat.  Methods  of  obtaining  the  milks  of  differ- 
ent fat  percentage  is  given  under  Holt's  Percentage  Milk  Method. 
Malt  soup  preparations  are  useful  where  the  child  is  not  gaining. 
Children  fed  on  milk  low  in  fat  and  protein  and  rich  in  carbo- 
hydrates are  apt  to  develop  rickets,  so  that  it  is  a  good  plan  to 
increase  the  fats  to  about  3  per  cent,  and  up  to  4  per  cent,  may  be 
used  in  many  cases.  The  top  milk  method  given  below  furnishes  an 
easy,  accurate  method  of  obtaining  mixtures  high  in  fat.  The  objec- 
tion to  the  high  fat  percentages  is  that  fat  seems  to  be  the  most 
difficult  part  of  the  food  for  the  infant  to  digest,  and  hence  fat  in- 
digestion is  common,  particularly  in  housed  city  children.  Active, 
out  door  babies  manage  fat  easily  as  a  rule.  The  breast  fed  baby 
digests  approximately  4  per  cent,  of  fat  and  in  our  experience  bottle 
fed  babies  on  the  higher  percentage  do  better  ultimately  than  the 
low  percentage  ones,  but  low  fat  feeding  is  better  in  infants  with 
weak  digestion  and  in  dispensary  or  similar  practice.  In  using  high 
fat  mixtures  the  interval  of  feeding  may  generally  be  lengthened  to 
advantage. 

Fat  indigestion  is  liable  to  happen  in  infants  fed  on  milk  from 
Jersey,  Alderney  and  Guernsey  cows.  Such  milk  usually  contains 
abnormally  high  fat  percentages  and  the  fat  droplets  are  large  and 
tend  to  coalesce.  The  milk  from  common  cows  is  better  as  the  fat 
droplets  are  smaller  and  the  percentage  lower.  Milk  from  Holstein 
cows  is  said  to  approach  human  milk  more  nearly  as  regards  its  fat 
containing  more  olein  and  less  of  the  volatile  glycerids. 

1  The  gruel  here  indicated  is  made  in  the  proportion  of  1  oz.  bv  volume  to  10  oz. 
of  water. 

2  Milk  sugar  is  here  indicated :  of  cane  sugar  use  two  scant  tablespoonfuls  in- 
stead of  two  and  a  half,  and  one  instead  of  one  and  a  half,  etc.  Maltose  may  be 
used  in  the  same  amounts  as  milk  sugar. 


282  INFANT  FEEDING 

In  fat  indigestion  the  baby  should  be  put  on  skim  milk  mixtures 
and  the  fat  percentage  gradually  increased,  always  keeping  well  in- 
side the  limit  of  tolerance.  Another  suggestion  is  to  use  skim  milk  to 
which  washed  butter  has  been  added;  some  of  the  fatty  acids  being 
soluble  in  water  are  thus  removed.  We  have  had  no  experience  with 
this  method. 

Children  getting  too  little  sugar  usually  are  slow  in  gaining.  If 
too  much  is  given  and  a  sugar  intolerance  created  or  if  the  child  is 
unable  to  utilize  sugar  in  any  quantity,  as  many  are  not,  especially 
after  diarrheal  disturbances,  food  low  in  sugar  may  be  given.  Omit- 
ting or  lessening  the  sugar  in  many  cases  is  sufficient.  In  severe 
cases  casein  or  eiweiss  milk  may  be  used  as  a  corrective  (see  same). 
It  is  only  a  temporary  expedient  and  not  suited  for  prolonged  use. 
Buttermilk  in  these  cases  is  often  of  great  service. 

If  the  protein  is  too  low  the  child  does  not  gain,  or  even  loses. 
Protein  indigestion  or  intolerance  varies  in  degree.  Many  times  it 
is  only  for  raw  milk  proteins  and  boiling  the  milk  relieves  the  condi- 
tion. The  addition  of  alkalis  to  prevent  clotting  in  the  stomach  or 
to  inhibit  gastric  digestion  entirely  may  be  tried,  or  whey  proteins 
may  be  more  largely  used  or  the  milk  may  be  peptonized  (pancreat- 
ized ) . 

Sometimes  intolerance  for  cow's  milk  exists  and  some  other  food 
must  be  used.  Cases  of  intolerance  where  the  infant's  digestion  has 
not  been  disturbed  by  faulty  feeding  are  rare,  but  intolerance  due  to 
unfortunate  methods  are  common.  Temporary  feeding  with  con- 
densed milk,  with  or  without  barley  or  soy  flour  or  both,  is  most  use- 
ful. Mammala  or  malted  milk  may  be  of  service  or  malt  soup  prepara- 
tions may  be  tried. 

Alkalis  such  as  lime  water,  etc.,  may  generally  be  dispensed  with, 
but  are  useful  in  certain  cases.  Fresh  fruit  juice,  as  orange  juice, 
is  a  valuable  adjunct  to  the  infant's  diet,  and  apparently  supplies 
something  necessary  for  growth  in  some  cases.  Purees  of  green 
vegetables  in  small  quantities  (one  quarter  to  two  teaspoonfuls)  may 
also  start  the  growth  in  a  baby  who  is  at  a  standstill. 

Laboratory  Feeding. — In  cities  the  best  substitute  for  breast-feed- 
ing is  furnished  by  milk  laboratories,  where  modifications  are  made 
according  to  the  physician's  prescription.  The  Walker-Gordon  lab- 
oratories, now  established  in  many  cities,  supply  an  ideally  clean 
milk,  unsterilized,  pasteurized,  or  sterilized  at  any  temperature  de- 
sired. The  milk  is  supplied  in  nursing-bottles,  each  bottle  holding 
enough  for  one  feeding  and  being  ready  for  use.  Beyond  warming 
the  bottle  and  putting  on  a  nipple  no  further  preparation  is  necessary. 
In  winter  the  milk  is  delivered  in  baskets,  and  in  summer  in  small 
refrigerators.  When  economy  must  be  practised,  the  milk  may  be 
obtained  in  larger  jars  and  divided  into  the  requisite  number  of  feed- 
ings by  the  mother  or  nurse.     Blank  forms  on  which  to  write  pre- 


MILK  MODIFICATION 


283 


scriptions  are  furnished  physicians, 
such  a  prescription : 


The  following  is  an  example  of 


^ 


Fats 


WALKER-GORDON  LABORATORIES 


(a)   Caebo-hydbates« 


Lactose  (Milk  Sugar) 
Maltose  (Malt  Sugar) 
Sucrose   (Cane  Sugar) 
Dextrose   (Grape  Sugar) 
Starch 


(b)  De^xteinize 

(c)  Protein- s^^'^^^ 

[  Casein 

(d)  Peptonize    

(e)  Sodium  CitbateJ  ^°  ""l  f'}^,  and  cream 

1  %  of  total  mixture  .  .  . , 

(f)  Sodium  Bicarb  i  J  «J  f  l^'^  and  cream 
^   '  1  %  of  total  mixture    .  . .  . 

of  milk  and  cream 

of  total  mixture 

Lactic  Acid  J  To  inhibit  the  saprophytes 

Bacillus       [  of  fermentation 

Other  Ingredients    


(g) 
(h) 
(i) 


Lime  Water 


1% 


Per  Cent. 


Heat  at. 


.'F. 


Number  of  Feedings- 


Amount  at  each  Feeding. 


ORDERED  FOR 


ADDRESS- 
DATE 


.1!» 


. M.  D. 

These  prescriptions  are  filled  at  the  laboratory  by  mixing  together 
milk,  cream,  standard  sugar  solutions,  and  water  in  the  proper  propor- 
tions. In  some  cases  a  16  per  cent,  gravity  cream  is  used,  and  in 
others  a  20  per  cent,  centrifugal  cream.  Other  things  being  equal,  it 
is  more  desirable  on  theoretic  grounds  to  use  gravity  cream. 

The  following  table  shows  a  series  of  formulae  of  varying  strength: 


Fat. 


Sugar.    Proteids. 


Separated  Proteids. 


Whev. 


Casein. 


Weak  Formulas 

\. 

1.00 

4.00 

0.25 

or 

0.20 

and 

0.05 

II. 

1.00 

5.00 

0.50 

<c 

0.45 

" 

0.05 

III. 

1.50 

5.00 

0.75 

" 

070 

n 

0.05 

IV. 

1..50 

6.00 

1.00 

le 

0.85 

" 

0.15 

Medium  Formulas 


V. 

2.00 

6.00 

i.no 

or 

0.85 

and 

0.15 

VI. 

2.50 

6.00 

1.25 

" 

0.80 

<« 

0.45 

VII. 

3.00 

6.00 

1.50 

ei 

0.85 

" 

0.65 

VIII. 

3.00 

6.00 

1.50 

« 

0.50 

« 

1.00 

284 


INFAyT  FEEDIXG 


Strong  Formulas       IX. 

3.50 

7.00 

1.75 

X. 

3.50 

7.00 

2.00 

XI. 

3.50 

7.00 

2.25 

XII. 

3.50 

7.00 

2.50 

XIII. 

4.00 

6.00 

3.00 

XIV. 

4.00 

4.75 

3.50   (Whole  Milk) 

For  a  small  or  a  delicate  child  or  one  with  feeble  digestion,  small  quantities  and 
the  weaker  formulas  are  advised. 

These  considerations  rather  than  the  age  of  the  child  should  determine  the  for- 
mula to  be  used. 

Tlie  separated  proteids  are  especially  recommended  for  all  the  weak  formulas. 

Recently  other  modifications  have  been  made  by  means  of  whey. 
The  whey  is  obtained  by  adding  rennin  to  the  milk,  or  Fairchild'.s 
Essence  of  Pepsin  may  be  used.  It  .should  be  heated  to  150°  F.  for 
five  minutes  before  being  added  to  the  milk  mixture,  in  order  to 
destroy  the  enzyme  in  the  milk  and  so  prevent  coagulation  of  the 
casein.  "When  whey  is  ordered,  the  protein  constituent  is  indicated 
in  the  prescription,  for  example,  as  follows : 

Casein   0.50 

Lactalbumin    0.75 

Rotch  gives  the  following  formulae,  showing  the  proportions  of 
whey  and  casein  as  a  guide  for  feeding  healthy  infants  where  it  is 
thought  desirable  to  split  the  proteins : 


Proteins  if 

1" 

a  E 

4>  3 

split. 

So 

^2 

bo 
a  ,^ 

«fe> 

isS 

Age. 

a 

m 

B 

^  bo 

c5 

.S.S 
-5^ 

ll 

1 

5 

2 

>.2 

O  <a 

< 

<U  CU 

is 

Premature     .    .  I 

1.00 
1.50 

4.00 
4.50 

0.25 
0.25 

0.25 
0.50 

0.25 
0.25 

}i-i 

1-u 

24-18 

At  tei-m    .... 

2.00 

5.00 

0.50 

0.50 

0.25 

1 

2 

10 

End  of  2d  week  . 

2.50 

5.50 

0.50 

0.50 

0.25 

1* 

2 

10 

End  of  3d  week  . 

3.00 

6.00 

0.75 

0.75 

0.25 

2 

2 

9 

End  of  4th  week  . 

3.50 

6.50 

1.00 

0.75 

0.50 

24 

2 

8 

End  of  6th  week  . 

4.00 

7.00 

1.00 

0.90 

0.60 

3 

^ 

7 

End  of  8th  week  . 

4.00 

7.00 

1.25 

0.90 

0.75 

3* 

'M 

7 

End  of  12th  week 

4.00 

7.00 

1.50 

0.90 

1.00 

4 

'M 

6 

End  of  4th  month 

4.00 

7.00 

1.50 

0.75 

1.25 

H 

iJi 

6 

Note. — The  above  formulas  are  somewhat  higher  in  fat  than  ordinarily  used  at 
present. 

In  most  cases  whey  mixtures  are  unnecessary.  In  acute  illness  or 
when  there  is  decided  lowering  of  the  protein  digestive  power  they 
may  be  of  great  service.  According  to  Grulee,^  the  albumin  content 
of  whey  varies  with  the  kind  of  rennet  used.  The  more  perfect 
tlie  curdling  of  the  casein,  the  more  desirable  is  the  whey  for  feeding 
infants. 

1  Archives  of  Pediatrics,  June,  1904. 


MILK  MODIFICATION 


285 


The   following  table,   from  Rotch,   gives  the   possibilities  of  such 
moditicatioii  in  the  milk  laboratory : 


Fat. 

Caseifi. 

Lactal- 
bumin. 

Sugar. 

Fat. 

Casein. 

Lactal- 
biimin. 

Suga 

1.00 

0.25 

0.25 

4-7 

2.50 

0.25 

0.50 

4-7 

1.00 

0.25 

0.50 

4-7 

2.50 

0.25 

0.75 

4-7 

1.00 

0.25 

0.75 

4-7 

2.50 

0.50 

0.50 

4-7 

1.00 

0.50 

0.25 

4-7 

2.50 

0.50 

0.75 

4-7 

1.00 

0.50 

0.50 

4-7 

2.75 

0.25 

0.25 

4-7 

1.00 

0.50 

0.75 

4-7 

2.75 

0.25 

0.50 

4-7 

L.-^O 

0.25 

0.25 

4-7 

2.75 

0.25 

0.75 

4-7 

1.50 

0.25 

0.50 

4-7 

2.75 

0.50 

0.50 

4-7 

1.50 

0.25 

0.75 

4-7 

2.75 

0.50 

0.75 

4-7 

1.50 

0.50 

0.25 

4-7 

3  00 

0.25 

0.25 

4-7 

1.50 

0.50 

0.50 

4-7 

.S.OO 

0.25 

0.50 

4-7 

1.50 

0.50 

0.75 

4-7 

3.00 

0.25 

0.75 

4-7 

2.00 

0.25 

0.25 

4-7 

3.00 

0.50 

0.25 

4-7 

2.00 

0.25 

0.50 

4-7 

3.00 

0.50 

0.50 

4-7 

2.00 

0.25 

0.75 

4-7 

3.00 

0.50 

0.75 

4-7 

2.00 

0.50 

0.50 

4-7 

3.50 

0.25 

0.50 

4-7 

2.00 

0.50 

0.75 

4-7 

3.50 

0.25 

0.75 

4-7 

2.25 

0.25 

0.25 

4-7 

3.50 

0.50 

0.50 

4-7 

2.25 

0.25 

0.50 

4-7 

3.50 

0.50 

0.75 

4-7 

2.25 

0.25 

0.75 

4-7 

4.00 

0.25 

0.25 

4-7 

2.25 

0.50 

0.50 

4-7 

4.00 

0.25 

0.50 

4-7 

2.25 

0.50 

0.75 

4-7 

4.00 

0.25 

0.75 

4-7 

2.25 

0.75 

0.50      ■ 

4-7 

4.00 

0.50 

0.25 

4-7 

2.25 

0.75 

0.75 

4-7 

4.00 

0.50 

0.50 

4-7 

2'50 

0.25 

0.25 

4-7 

4.00 

0.50 

0.75 

4-7 

In  order  to  obtain  satisfactory  results  the  suDJeet  of  laboratory 
feeding  must  be  thoroughly  studied.  The  authors  have  adopted 
Holt's  scheme  of  having  weekly  reports  made  on  all  artificially  fed 
infants  and  on  many  others.  These  reports  are  supplied  in  blank 
form,  in  pads,  to  the  mother,  who  fills  out  one  each  week  and  sends  it 
to  the  physician.  By  this  method  part  of  the  responsibility  is  placed 
on  the  mother,  and  the  physician  is  kept  informed  as  to  the  infant's 
condition  and  needless  visits  are  thus  obviated.  The  following  ^  is  a 
specimen  of  .such  form  : 

1  From  Holt,  Diseases  of  Infancy  and  Childhood,  p.   184. 


286 


INFANT  FEEDING 


?5^ 


« 

^ 


^S^ 

^" 

.gi 

'o 

s 

<a 

^ 


so 


i=5 


!35 


<3 


-^ 


Si. 

Si- 


■^ 

o 

o 


^ 
g 
e 


2 


rS; 


■^ 


^ 


Si. 


'TS 


53 


^  "Si 


MILK  MODIFICATION 


287 


The  percentage  of  fat,  protein,  and  sugar  required  by  an  infant 
of  any  given  age  nuist  be  borne  in  mind  if  one  is  to  use  any  method 
of  percentage  feeding.  The  following  schedule  will  be  found  useful 
as  an  aid  to  the  memory.  The  figures  for  intermediate  ages  are  easily 
calculated : 

Schedule  for  Average  Infants. 


Age. 

Percentage. 

Average  quantity  for 
cue  feeding. 

Number 

of 
feedings 

Interval 
by  day. 

1 

Fat. 

Sugar. 

Protein. 

Ounces. 

Grams. 

24  hours. 

Premature  infants 

1.0 

4.0 

0.25 

M 

10-20 

12-20 

1-1^  hours 

lst-2d  day  .    .    . 

5.0 

1-1 A 

30^6 

4-6 

6^        " 

2d-8th  day  .    .    . 

2.0 

6.0 

6.50 

U 

45 

10 

2 

3d  week   .... 

2.5 

6.0 

0.75 

2" 

60 

10 

2 

2d  month     .    .    . 

3.0 

6.0 

1.00 

3 

90 

9 

2i       " 

3d  month     .    .    . 

3.0 

6.5 

1.25 

3J 

110 

8 

3 

4th  month    .    .    . 

3.5 

7.0 

1.50 

4" 

125 

■7 

3 

5th  month    . 

3.5 

7.0 

1.75 

5 

160 

7 

3 

6th-10th  month  . 

4.0 

7.0 

2.00 

7 

220 

6 

3 

11th  month  .    .    . 

4.0 

5.0 

2.50 

8 

250 

5 

4 

12th  month  .    .    . 

4.0 

5.0 

3.00 

9 

280 

5 

4 

Later 

4.0 

4.5 

3.50 

9 

300 

5 

4         " 

The  quantity'  should  be  increased  half  an  ounce  or  an  ounce  at  a 
time.  Later,  as  the  child's  appetite  grows  stronger, — that  is,  when 
he  seems  dissatisfied  after  his  bottle, — the  quality  is  raised.  The  fat 
may  usually  be  increased  0.5  per  cent,  at  a  time;  the  sugar,  0.5  to  1 
per  cent,  at  a  time ;  the  proteins,  from  0.1  to  0.25  per  cent,  at  a  tim.e. 
Strong,  healthy,  large  babies  require  more  and  richer  milk  than  those 
of  frailer  constitution. 

What  is  known  as  nursery  milk  is  also  supplied.  This  is  from  a 
selected  herd  of  cattle  whose  milk  contains  the  fat  in  very  small 
globules.  This  is  said  to  be  more  easily  digested,  especially  by  weak 
infants. 

Holt's  Percentage  Milk  Method. — Holt  has  devised  two  methods 
of  modifying  milk  which  are  very  useful.  The  following  method  at 
first  sight  looks  very  complicated,  but  it  is  not,  and  it  permits  of  great 
numbers  of  reasonably  exact  formulge.  The  first  step  is  to  obtain 
milk  containing  definite  amounts  of  fat  from  7  per  cent,  down  to  1 
per  cent.  Ordinary  market  milk  from  mixed  herds  averages  4  per 
cent.,  milk  from  Jerseys,  and  Alderneys,  5  per  cent,  or  more. 

Uniform  results  may  be  obtained  by  having  patients  use  milk  from 
one  dairy  or  by  having  them  buy  milk  containing  a  certain  percentage 
of  fat  from  milk  laboratories. 

For  convenience  the  formulge  are  calculated  for  20-ounce  mixtures. 

Every  ounce  of  7  per  cent,  milk  in  20-oz.  mixture  has  one-twentieth  of  7,  or 

0.35  per  cent.  fat. 

Every  ounce  of  (i  per  cent,  milk  in  20-oz.  mixture  has  one-twentieth  of  6,  or 

0.30  per  cent.  fat. 


288  INFANT  FEEDING 

Every  ounce  of  5  per  cent,  milk  in  20-oz.  mixture  has  one-twentieth  of  5,  or 

0  25  per  cent.  fat. 
Every  ounce  of   1   per  cent,  milk  in  20-oz.  mixture  has  one-twentieth  of  0.05 

per  cent,  fat 

The  variations  in  protein  and  sugar  need  not  be  considered.  Four 
per  cent,  milk  contains  4.50  per  cent,  sugar  and  3.50  per  cent,  pro- 
tein, so  each  ounce  of  4  per  cent,  miliv  in  any  of  the  formukv  in  a 
20-ounce  mixture  will  contain  one-twentieth  or  0.225  per  cent,  sugar 
and  0.175  per  cent,  protein. 

The  tables  from  Holt  show  the  variations  that  may  easily  be  ob- 
tained. To  raise  the  fat  without  the  protein,  use  a  milk  of  a  higher 
fat  percentage.  To  raise  the  protein  and  not  the  fat.  use  more  ounces 
of  the  same  milk,  or  even  of  a  weaker  one  if  need  be. 

The  necessary  sugar  is  added,  remembering  that  each  ounce  of  milk- 
sugar  by  weight  in  a  20-ounce  mixture  increases  the  sugar  5  per 
cent.,  or  each  ounce  by  volimie  about  3  per  cent.,  and  that  each  level 
tablespoonful  in  a  20-ounce  mixture  increases  the  sugar  about  1.75 
per  cent. 

These  formulae  give  rather  low  fat  percentages,  but  otherwise  are 
sufficiently  elastic  to  suit  all  needs.  As  a  matter  of  fact,  compara- 
tively few  variations  are  recjuired  except  in  difficult  cases. 

Top=milk  Method. — The  top-milk  method  consists  in  using  the 
mixture  of  cream  and  milk  in  the  upper  one-third  or  upper  one-half 
of  a  jar  of  milk  that  has  been  allowed  to  stand  for  some  time.  Later, 
the  whole  milk  may  be  used.  This  method  works  satisfactorily  onlj' 
when  the  milk  is  bottled  soon  after  milking,  before  the  cream  has 
separated.  For  those  who  cannot  obtain  such  milk  the  necessary 
mixture  of  cream  and  milk  may  be  made  as  indicated  by  the  table. 
The  top  layer  of  cream  may  be  removed  from  the  bottled  milk  with 
a  spoon ;  the  remainder,  by  means  of  a  small  dipper ;  for  this  purpose 
a  Chapin  milk-dipper,  which  may  be  obtained  at  any  drug-store,  will 
be  found  very  useful.  Another  method  is  to  use  a  siphon.  The  plan 
of  pouring  off  the  upper  one-third  is  not  nearly  so  reliable.  After 
it  has  been  removed,  and  before  the  required  portion  is  taken  out, 
the  entire  upper  one-third  or  one-half,  as  the  case  may  be,  should 
be  thoroughly  mixed. 

The  following  tables  require  no  explanation.  When  desired,  the 
percentage  of  lime-water  may  be  increased,  or  it  may  be  replaced  by 
sodium  bicarbonate,  1  grain  or  more  per  ounce,  if  the  milk  is  to  be 
boiled.  If  the  quantity  required  exceeds  20  ounces,  the  smaller  sup- 
plementary tables  may  be  used,  or  the  quantity  may  easily  be  cal- 
culated by  adding  an  additional  one-fourth  to  each  item  for  25  ounces, 
or  one-half  more  for  30  ounces,  etc. 

The  sugar  may  be  measured  by  means  of  a  pill-box  holding  exactly 
an  ounce,  or  veiy  conveniently  by  allowing  three  level  tablespoonfuls 
of  milk-sugar  to  the  ounce.  When  cane-sugar  is  used,  two  level  table- 
spoonfuls  is  sufficient.     Dry  measure  of  sugar  is  just  twice  that  of 


MILK  MODIFICATION 


289 


.r 


(MiCiOOOiOiOOOU^iOOOiCiO 

C^rti^a:  .-iCOiOOOO(MTt<t^a2.-HCC 

oooor-<r-ir-;i-ic^c<ic<ic<ic4eoeo 

^.  .........  =  =  .  = 

CO 

t^iCOOkOKtiOOO'OOOiOOO 
.-iCOiOI:^OOOiM-*iCOt>-Oii-H(M-fH<© 

ooooO'-Hi-!,-H^i-Hi-;c<ic<ic<i<?4 

With  protein. 

G. 
1  per 
cent, 
milk. 

lOOiOOiCOiOOiOOiCOiCOiO 
Oi-i^(M<MeOCCTt<rtiu:)iOi:0'X)t^t> 

ddoooooodddoood 

F. 
2  per 
cent, 
milk. 

ooooooooooooooo 
.-icicorriiocoi^oooiOi-iMco-^io 
dddddddddi-HrHr-HT-HrH.-i' 

E. 
3  per 
cent, 
milk. 

lOOiOOiOOiCOiCOiOOiCOiO 

i-(ccTticoi>-oiOc<icoio'»ooo5i— iM 

ddddddrHrHrHi-HrHrHi-HOvjlM* 

t,   ..•        ooooooooooooooo 

■^aH            <M-^'»OOOC^5'*'OOOOC<J':t<<»000 

■*  u  a 

C. 
5  per 
cent, 
milk. 

iC  O  iC  O  lO  O  »0  O  lO  O  lO  O  iC  o     • 
(MiOt:^Oe<)iOt^O'M"t>t^OC<liO 

d  d  d --i  >-<  T-5 1-H  iri  c<j  c<i  c4  eo  CO  SO    ' 

B. 

6  per 
cent, 
milk. 

o oooo ooooo oo o    •    ■ 
eoi»oi(Mioao^_'*_t-;Oco'»05 
ddd'-Hi-H>-ic<is^c-Jcocococo    ' 

A. 

7  per 
cent, 
milk. 

lOOU^OiOOiOOiOOO     -     •     •     • 
COt^O-^t^T-H-^oOOiOOO 

dd^^-H(i4c<ic^icoeo'co    '    *    *    * 

1  ounce  in  20  has  fat  . 

2  ounces  in  20  have  fat 

3  "                 " 

4  «                 " 

5  "                 " 

6  "                 " 

8  "                     " 

9  "                " 
10         "                " 
11 

12 

13 

14         "                 " 

15 

c<ieo  icoo 

fe 

o 

a 

6C 

a-  - 

- 

Ss. 

s 

^ 

^  ^ 

93 

u.^ 

s 

«Ci  *J 

13 


&I2 
o-    S 


^  o 


J. 2 


^  S' 


Cz    z 

h-a 

3 

^T5 

O 

^    « 

<MtJ.oo 

o 

be 

-^'r? 

s 

2-g 

3    " 

1  i) 

^ 

-  ^ 

OS 

ac-a 

s  &o 

:; «  -2^ 

§3 ^> 

^  M  J  J 

■§■"    -  II 

■tJ  o  o 

"----  =  -  J=J 

t^  «o  o  '^  eo  IN  i-H 
a 


weighing.     Thus,  one  ounce  of  sugar  by  weight  would  measure  two 
ounces  in  a  measuring-glass. 
19 


290 


INFANT  FEEDING 


The  following  formulas  have  been  taken  from  Holt :  ^ 

First  Series  of  Formulas. — Fat  to  Protein,  3 : 1. 

Primary  Formula. — Ten  per  cent,  milk — fat.  10  per  cent.;  sugar, 
4.3  per  cent.;  proteins,  3.3  per  cent.  Obtained — (1)  as  upper  one- 
third  of  bottled  milk  or  (2)  equal  parts  of  milk  and  16  per  cent, 
cream. 

Derived  formulas,  giving  quantities  for  20-ounce  mixtures: 


f  Milk-sugar    ...    1  oz. 
Lime-water    ...    1  oz. 
Water,  q.s.  ad.  20  oz. 
2. 
3. 

4.  "  "  " 

5. 
6. 


with  2  oz.   10  p.c.  milk 

"     3  oz. 

"     4  oz. 

"     5  oz. 

"     6  oz. 

"     7  oz. 


Fat 
per  cent. 

Sugar 
per  cent. 

Protein 
per  cent 

.    1.00 

5.50 

0.33 

.    1..50 
.    2.00 
.   2.50 
.    3.00 
.    3.50 

5. .50 
6.00 
6.00 
6.00 
6. .50 

0.50 
0.66 
0.83 
1.00 
1.16 

Table  Giving  in  a  Condensed  Form  the  Quantities  Usually  Required  for 
Obtaining  the  Different  Fat-percentages. 

ABCDEFGH   I    JKLMNO 

To    obtain    fat.    per  |  ,,  -q     ^q     ^5     2q     2.0     2.5     2.5     2.75     3.0     3.0     3.0     3.25     3.5     3.7     4.0 

cent ) 

For       total       food 

ounces     

Take     10     per    cent.  1^^-^^     ^^ 


1.50     1.0     1.5 

0.20  20.0  20.0  20.0  25.0  25.0  28.0  28.00  30.0  33.0  36.0  36.00  37.0  38.0  40.0 
2.0     4.0     5.0     6.0     7.0     8.00     0.0  10.0  11.0  12.00  13.0  14.0  16.0 


milk,    ounces     ...  J 

Proteins:     The  percentage  in  each  case  will  be  one-third  fat. 

Sugar:  1  ounce  in  20,  or  1  tablespoonful  in  8  ounces,  gives  5.5  per  cent,  for  the 
lower  and  6.5  for  the  higher  formulas. 

Lime-water:   1  part  to  20  of  the  food,  the  average  required. 

Water:  Sufficient  to  be  added  to  the  foregoing  ingredients  to  bring  the  total 
to  the  number  of  ounces  specified;  in  part  of  this  water  the  milk-sugar  is  dis- 
solved.    Barley-w^ater  or  any  other  diluent  may  be  added  in  the  same  manner. 

Second  Series  op  Formulas — Fat  to  Protein,  2 : 1. 

Primary  Formula. — Seven  per  cent,  milk — fat,  7  per  cent.;  sugar, 
4,4  per  cent.;  protein,  3.5  per  cent.  Obtained — (1)  as  upper  one- 
half  of  bottled  milk,  or  (2)  by  using  3  parts  of  milk  and  1  part  of  16 
per  cent,  cream. 

Derived  formulas,  giving  quantities  for  20-ounce  mixtures: 


f  Milk-sugar    ...    1  oz. 
1.  \  Lime-water    ...    1  oz. 
[  Water,  q.s.  ad.  20  oz. 


with  3  oz.  7  p.c.  m 


ilk 


2. 

" 

4  oz. 

3. 

" 

5  oz. 

4. 

" 

6  oz. 

5. 

" 

7  oz. 

6. 

" 

8  oz. 

7. 

" 

9  oz. 

8. 

(C 

10  oz. 

fMilk 

sugar    . 

.    2oz.] 

. 

9. 

■I  Lime 

-water    . 

.  1  oz. : 

(I 

12  oz. 

Fat 

Sugar 

Protein 

per  cent. 

per  cent. 

per  cent. 

.    1.00 

5.50 

0.50 

.    1.40 

5.75 

0.70 

.    1.75 

6.00 

0.87 

.   2.10 

6.00 

1.05 

.   2.50 

6.50 

1.25 

.   2.80 

6.50 

1.40 

.   3.15 

7.00 

1.55 

. '  3.50 

7.00 

1.75 

4.00 


7.00 


2.00 


[  Water,  q.s.  ad.  2,0  oz.  J 

1  Diseases  of  Infancy  and  Childhood,  pp.  189,  191,  192. 


MILK  M0DlFlCAT10:s  291 

Table  Giving  in  a  Condensed  Form  the  Quantities  Usually  Required  for  Obtaining 
the  Different  Fat-percentages. 

AB        CDE  F  G        H        I  JKLM 

To  obtain  fat,   percent 1.0     1.0     1.4     1.8     2.0  2.33  2.75  3.75     3.1  3.5     3.5     4.0     4.0 

For    total    food,    ounces 20.0  30.0  30.0  33.0  33.0  36.00  30.00  40.00  40.0  40.0   44.0   44.0   48.0 

Take  7  i)er  cent.  milk,  ounces.  3.0     4.0     6.0     8.0   10.0  12.00  14.00  16.00  18.0  20.0  22.0  25.0  28.0 

To  obtain  the  e.\act  fat-percentage  take  one-third  the  number  of  ounces  of 
top-milk  in  a  20-ounce  mixture  and  add  0.15  to  the  result.  In  practice  this  slight 
error  may  be  disregarded. 

Proteins:     The  percentage  in  each  case  will  equal  one-half  of  the  fat. 

Sugar:  1  ounce  in  20,  or  1  even  tablespoonful  in  8  ounces,  until  the  food 
becomes  half  milk;  after  that  1  ounce  in  25,  or  1  even  tablespoonful  to  each  10 
ounces  of  the  food,  will  give  the  proper  amoimt. 

Lime-water:      Usually  in  the  proportion  of  1  part  to  20  of  the  total  food. 

Water  or  other  diluent:  Sufficient  to  be  added  to  the  foregoing  ingredients 
to  make  the  total  number  of  ounces  specified;  in  part  of  this  the  sugar  is  dis- 
solved. 

Third  Series  of  Formulas — Fat  to  Protein,  8 :  7. 
Primary  Formula.- — Plain  milk — fat,  5  per  cent.;  sugar,  4.5  per 
cent. ;  proteins,  3.5  per  cent. 

Derived  formulas,  giving  quantities  for  20-ounce  mixtures: 

Fat  Sugar  Protein 

■per  cent.  per  cent.  per  cent. 
f  ]Milk-sugar     .  .  .    1  oz  1 

l.-J  Lime-water    ...    1  oz.  j^with  5  oz.  plain  milk    ...    1.00  6.00  0.87 

[  Water,  q.s    ad.  20  oz.  J 

2.          "          •'               "             "     6  oz.       "           "...    1.20  6.00  1.00 

.3.          "           "                "              "     8  oz.       "           "...    1.60  G.50  1.40 

4.  •■'          "               "             "   10  oz.       "           "      .  .  .    2.00  7.00  1.75 
f  Milk-sugar    ...   i  oz.  "1 

5.  ^  Lime-water    ...   ^  oz.  J-      "  12  oz.       «  «...   2.40  5.00  2.10 
[  Water,  q.s.  ad.  20  oz.  J 

6.  "  ■'  '•  "  14  oz.       ••  ••      :  .  .   2.80  5.50  2..50 

7.  "  "  "  •'   10  oz.       ■•  ■•      .  .  .   3.20  5.50  2.80 

Table  Giving  Quantities  of  16  per  cent.  Milk  Required  for  Obtaining  Formulas 
with  High  Fat  and  Low  Protein. 

ABCDEFGH        I        JK 

To   obtain    fat,    per    cent 1.6     1.6     2.0     2.5     3.0     3.0     3.0     3.5     3.5     4.0     4.0 

For    total   food,    ounces    30.0  30.0  30.0  32.0  32.0  37.0   ik\()   36.0  40.0  4(i.O   44.0 

Take    16   per    cent,    milk,    ounces 2.0     3.0     4.0     5.0     6.0     7.0     8.0     8.0     9.0   10.0  11.0 

Proteins  in  all  cases  will  be  one-fifth  the  fat. 

Sugar:  1  even  tablespoonful  for  each  8  ounces  will  give  5.5  per  cent,  for  the 
lower  formulas  (A,  B,  C,  etc.)  and  6  per  cent,  for  the  higher  formulas  (G,  H,  I, 
etc. ) . 

Lime-water :      1  ounce  to  20  ounces  of  the  food  will  give  5  per  cent: 

Materna  Graduate  Method. — The  very  simple  and  useful  appa- 
ratus known  as  the  Estraus  Materna  Graduate  is  of  great  value  where 
one  can  not  secure  intelligent  cooperation  in  the  home,  and  also 
where  there  are  no  facilities  for  milk  preparation.  This  method  of 
infant  feeding  has  been  tried  by  the  authors  for  several  years  in  the 
Kobert  Garrett  Free  Hospital  for  Children,  Baltimore,  and  too  much 
can  not  be  said  regarding  its  simplicity  and  efficiency.  With  its  six 
formulas,  however,  it  is  not  adaptable  to  all  eases,  some  infants  being 
totally  incapable  of  taking  the  step  from  one  formula  to  another. 

The  apparatus  consists  of  a  glass  jar  with  a  lip  and  seven  panels, 
and  a  capacity  of  16  ounces.     One  of  the  panels  exhibits  an  ordinary 


292 


I^'FAXT  FEEDING 


ounce  graduation;  the  other  six  panels  present  six  different  formulas 
for  the  modification  of  cows'  milk,  each  formula  being  so  arranged 
as  to  keep  pace  with  the  infant's  growth,  viz. : 

Fat 2  per  cent.  2i  per  cent.  3  per  cent.  3 J  per  cent.  4  per  cent.  3i  per  cent. 

Sugar 6         '•         6  "'         6         "  7  '         7         "         3^         " 

Protein  ....0.6      "        0.8        "         1         "  U         •■         2         "         2i 

For  Formula  6  see  special  instructions  below. 


Milk  .... 
Cream  .  .  . 
Lime-water 
Water  .  .  . 
Milk-sugar 


.d 

ji 

2^ 

Si 

S 

"§ 

Si3 

o  ^ 

5^ 

la 

J35 

o  c 
■"  o 

!0 

parts 

IK 

1% 

2 

4»^ 

6 

" 

-^% 

2 

2 

2 

;; 

1 

12^ 

\1% 

iZ 

1 

Milk  ....  parts 
Cream  ...     " 
Barley-gruel    " 
Granulated  sugar, 
parts  ...... 


9% 
1 


Having  decided  which  formula  is  to  be  used,  the  panel  containing 
that  formula  is  the  only  one  to  be  followed. 

The  quantity  desired  for  twenty-four  hours  is  next  to  be  considered, 
and  the  apparatus  filled — once,  if  16  ounces  or  less  are  required  for 
the  twenty-four  hours;  twice,  if  from  16  to  32  ounces  are  required 
for  tlie  twenty-four  hours;  three  times,  if  from  32  to  48  ounces  are 
required  for  the  twenty-four  hours. 

Directions. 
(The  lines  beneath  the  words  indicate  the  points  to  which  the  various 
ingredients  are  to  be  filled  in.) 

1.  Milk-sugar. — Introduce  milk-sugar  to  the  line  so  marked.  Where 
good  milk-sugar  can  not  be  obtained,  granulated  sugar,  in  just  half 
the  quantity,  should  be  used.  A  small  cross  on  the  apparatus  in- 
dicates this  point.     i,See  directions  for  Formula  7.) 

2.  \yater. — Add  boiled  water  (hot)  to  the  water-mark,  and  stir 
until  the  sugar  is  dissolved.  If  a.nj  particles  are  seen  floating  in  the 
solution,  it  should  be  filtered  either  through  absorbent  cotton  or 
through  two  thicknesses  of  clean  muslin. 

3.  Lime-water. — Ordinary  lime-water,  such  as  is  obtained  at  drug- 
stores, should  then  be  filled  to  the  L-water  mark. 

4.  Cream. — This  should  be  the  ordinary  cream  (16-20  per  cent.) 
as  obtained  in  bottled  milk;  it  should  be  poured  in  to  the  cream  mark. 
If  the  cream  is  purchased  separately,  ordinary  cream,  and  not  centrif- 
ugal cream  should  be  used. 

5.  Milk. — Ordinary  good  cows'  milk  should  be  used  and  the  jar 
filled  to  the  milk  mark. 

6.  The  entire  mixture  should  next  be  stirred. 

7.  The  whole  should  then  be  poured  into  separate  bottles  and  steril- 
ized if  desired,  or  stoppered  with  cotton  and  immediately  placed  upon 
ice. 


MILK  .MODIFICATION 


293 


Directions  for  formula  6. — 1.  Sugar. — In  this  formula  granulated 
sugar  should  be  used  in  place  of  inilk-sugar,  and  the  sugar  introduced 
into  the  vessel  to  the  line  thus  marked. 

2.  Barley-gruel. — In  this  formula 
barley-gruel  should  be  used  instead 
of  water,  and  the  glass  tilled  to  the 
line  thus  marked.  Bai'ley-gruel 
should  be  prepared  as  follows:  To 
I  tablespoonful  of  pearl  barley,  after 
soaking  for  several  hours,  add  1  pint 
of  water,  a  pinch  of  salt,  and  boil 
for  live  or  six  hours,  adding  water  as 
necessary.  Strain  through  muslin. 
Or  the  following  method  may  be  used : 
1  rounded  tablespoonful  of  any  good 
barley  flour;  rub  up  with  cold  water, 
and  add  to  1  pint  of  boiling  water; 
cook  for  fifteen  minutes,  stir,  and 
strain  if  lumpy. 

3.  Cream.  4.  31  ilk. — Add  the  same 
as  in  other  formulas. 

5.  Stir.  6.  Sterilize. — Same  as  in 
other  formulas. 

The  Deming  Modifier. — Another  ingenious  graduate  for  obtaining 
percentages  is  called  the  Deming  modifier,  which  has  on  it  the  follow- 
ing markings : 

Graduations  and  Markings. 


Fig.  2. — Deming's  milk  modifier. 


Proteins. 

Fat. 

Use  4^ 

milk  or 

whole 

milk. 

Use  5/o 
milk  or 
the  top 
24  ounces 
from  1 
quart. 

Use  &f 
milk  or 
the  top 
20  ounces 
from  1 
quart. 

Use  7?^ 
milk  or 
the  top 
16  ounces 
from  1 
quart. 

Use  Vdi 
milk  or 
the  top 
11  ounces 
from  1 
quart. 

Use  12?f 
milk  or 
the  top 
9  ounces 
from  1 

(Top  line). 

quart. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

2.8 

3.5 

4.4 

6.2 

6.0 

8.6 

10.4 

2.6 

3.2 

4.0 

4.8 

5.6 

8.0 

9.7 

2.4 

3.0 

3.7 

4.5 

5.2 

7.5 

9.0 

oo 

2.7 

3.4 

4.0 

4.8 

6.8 

8.2 

2.0 

2.5 

3.0 

3.7 

4.4 

6.2 

7.5 

1.8 

2.2 

2.8 

3.3 

3.9 

5.6 

6.7 

1.6 

2.0 

2.5 

3.0 

3.5 

6.0 

6.0 

1.4 

1.7 

2.2 

2.6 

3.0 

4.3 

6.2 

1.2 

1.5 

1.8 

2.2 

2.6 

3.7 

4.5 

1.0 

1.2 

1.5 

1.8 

2.2 

3.1 

3.7 

.80 

1.0 

1.2 

1.5 

1.7 

2.5 

3.0 

.60 

.75 

.95 

1.1 

1.3 

1.8 

2.2 

.40 

.50 

.62 

.75 

.88 

1.3 

1.5 

.20 

.25 

.30 

.38 

.44 

.62 

.75 

294 


INFANT  FEEDING 


Directions. — Pour  whole  milk  or  top  milk  up  to  desired  percentage  of  proteins. 
Then  add  gruel  or  water  to  toj)  line.  This  makes  10  ounces.  The  top  milks  are 
to  be  removed  from  1  quart  of  milk  after  the  cream  has  risen. 

1  level  tablespoonful  of  granulated  sugar  =  2 A  per  cent. 

2  level  tablespoonfuls  of  granulated  sugar  =  5  per  cent, 
li  level  tablesjjoonfuls  of  milk-sugar  ^  2^  per  cent. 

3  level  tablespoonfuls  of  milk-sugar  ^  5  per  cent. 

To  add  5  per  cent,  of  lime-water  leave  out  1  ounce  of  gruel  or  water  and  replace 
with  lime-water.  To  make  8  ounces,  pour  milk  uj)  to  one-half  desired  percentage 
of  protein  and  add  gruel  or  water  to  8-ounce  lime.  Use  one-half  quantity  of 
sugar. 

To  ascertain  what  milk  to  use  to  obtain  any  desired  combination  of  protein  and 
fat,  pick  out  the  desired  percentage  of  proteins  in  the  protein  column.  Then 
move  in  a  horizontal  line  to  the  right  until  the  desired  percentage  of  fat  is  found. 
The  heading  of  the  fat  column  shows  what  milk  to  use.  The  percentage  of  sugar 
in  the  diluted  milk  is  almost  exactly  the  same  as  the  percentage  of  protein. 

Maynard  Ladd's  Table.^ — Another  method  of  modifying  milk  is 
according-  to  ]\Iaynard  Ladd's  table.  In  this  the  quantities  have  been 
estimated.  This  method  is  useful  in  hospitals  where  there  is  a  milk 
laboratory.  In  general  practice  it  is  of  slight  value,  for  it  necessitates 
memorizing  a  lengthy  table,  or  carrying  it  about,  both  of  which 
methods  are  open  to  objection. 


Prescriptions  call- 
ing fora  mixture 

Cream  in  ounces 

. 

Fat-free  milk  in  ounces 
used  with  creams  of— 

of  20  ounces. 

a 

a»_^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

'-'  S 

fi 

a 

a 

a 

(3 

13 

(3 

c 

'S    rA 

?  2 

*  ?, 

aj 

<v 

o 

<D 

<u 

0) 

0) 

0) 

°^  Sfj 

boS 

a 

1*  ^ 

o 

o 

o 

a 

o 

u 

o 

o 

^g 

S" 

i 

C3 

as. 

o 
P. 

f-t 

0) 

0) 

ft 

ft 

ft 

o  c 

7  o5 

:;3  3 

03 

^ 

PL, 

'hJ 

o 

N 

to 

S 

o 

IN 

o 

s 

^ 

PQ 

s 

0.50 

5.00 

2.00 

5 

1 

i 

i 

i 

9J 

n 

9J 

91 

.| 

8| 

H 

0.75 

6.00 

1.00 

5 

n 

n 

1 

1 

3J 

3| 

4 

4i 

14 

2i 

1.00 

5.00 

0.75 

5. 

2 

n 

n 

1 

2 

2* 

2i 

3 

15 

2 

1.50 

4.00 

0.50 

5 

n 

2^ 

2 

u 

C) 

i 

1 

U 

16i- 

u 

2.00 

5.00 

0.75 

5 

4 

3 

k 

ll 

0 

1 

H 

2} 

15 

2 

2.00 

5.50 

1.00 

5 

4 

3 

2i 

If 

H 

2i 

21 

3^ 

13^ 

2i 

2.50 

6.00 

1.00 

5 

5 

4 

3i 

n 

0 

H 

2i 

3 

14 

2| 

3.00 

6.00 

0.50 

5 

n 

(0 

3| 

3 

r) 

D 

0 

f 

15i 

If 

3.00 

6.00 

0.75 

5 

{') 

5 

3| 

3 

/IS 

0 

li 

2 

14 

2i 

3.00 

6.00 

1.00 

5     (M 

41 

3| 

21 

i 

1| 

2| 

13^ 

2i 

3.50 

6.50 

1.00 

5'M 

5^ 

^ 

3^ 

r) 

0 

1 

2 

m 

^ 

3.50 

6.50 

1.50 

5  i7 

5^ 

^ 

3* 

1 

2| 

H 

^ 

11 

2^ 

3.00 

7.00 

1.00 

5 

n 

41 

3| 

21 

n 

4 

i| 

2| 

13J 

2| 

3.00 

7.00 

1.50 

5 

6 

4| 

3| 

21 

2 

3i 

4i 

5i 

11 

2J 

3.00 

7.00 

2.00 

5 

6 

4| 

3| 

21 

^ 

5| 

6| 

7| 

81 

2i 

4.00 

7.00 

1.00 

5 

(') 

{') 

5 

3i 

n 

(M 

^ 

1| 

13^ 

2| 

4.00 

7.00 

1.50 

5 

8 

6i 

5 

31 

0 

If 

3 

^ 

11 

2| 

4.00 

7.00 

2.00 

5 

8 

6i 

5 

31 

2J 

4} 

5J 

6| 

8| 

2^ 

4.00 

7.00 

2.50 

5 

8 

6i 

5 

31 

6 

61 

8 

9i 

6 

2 

4.00 

7.00 

3.00 

5 

8 

6} 

5 

31 

7h 

9i 

10^ 

111 

^ 

2 

4.00 

6.00 

3.00 

5 

8 

6i 

5 

3f 

n 

9i 

lOi 

111 

3* 

li 

4.00 

5.00 

3.00 

5 

8 

6i 

5 

31 

n 

9} 

io| 

111 

3^ 

1 

4.00 

5.00 

3.50 

5 

8 

6k 

5 

31 

10 

Hi 

13 

14^ 

1 

* 

1  Taken  from  Rotch's  Pediatrics. 

(1)  Indicates  that  the  combination  is  impossible  with  the  percentage  of  cream 
given . 


MILK  MODIFICATION  295 

Baner's  Method.— Many  attempts  have  been  made  from  time  to 
time  to  compute  a  table  of  equations  from  whicli  the  quantities  of 
milk,  cream,  etc.,  may  be  determined  for  any  given  mixture;  the 
simplest  of  these  is  that  of  Baner :  ^ 

Quantity  desired  (in  ounces)  ^=  Q. 

Desired  percentage  of  fat  ==  P. 

Desired  percentage  of  sugar  =  8. 

Desired  percentage  of  protein  =  P. 
To  find  in  ounces — 

Cream   (16  per  cent.)  ^— X  {F P). 

Milk  -JD<L_  c. 


4 
Water  :=  Q  —  (('  +  M  ) . 

Dry  milk-sugar 


(*S'  — /')   X  0 


UM) 


Example. — Suppose  it  is  desired  to  make  40  ounces  of  a  4  per  cent, 
fat,  7  per  cent,  sugar,  2  per  cent,  protein  mixture.  By  substituting 
the  figures  in  the  ecjuations  above  we  have — 


40 
Cream     =— X  2  ^  6§  ounces. 

40  X  2 
Milk        = ; —  —  H  =  13;^  ounces. 

Water     =  40  —  20  =  20  ounces. 

Q  5  X  40 

bugar      = —  =  2   ounces. 


Technic  of  Modifying  Milk  at  Home.^ — To  insure  success  in  home 
modification  a  very  careful  technic  must  be  followed  by  the  mother 
or  the  nurse.  In  the  absence  of  a  nurse  specially  trained  for  the 
purpose  it  becomes  necessary  for  the  physician  to  give  careful  written 
and  verbal  instructions,  and  then  to  see  personally  that  these  are 
carried  out.  Knowledge  on  the  part  of  the  mother  or  nurse  should 
not  be  assumed,  for,  as  a  rule,  she  does  not  possess  it.  There  are 
many  nurses,  both  graduate  and  otherwise,  whose  conceptions  of  in- 
fant feeding  and  milk  preparation  are  practically  useless.  Like  many 
medical  students  and  recent  graduates,  they  understand  more  about 
laparotomies  than  they  do  about  milk.  If  this  is  borne  in  mind,  many 
unpleasant  experiences  may  be  avoided. 

The  vessels  and  instruments  used  should  be  kept  scrupulously  clean, 
and  be  used  solely  for  the  purpose  intended.  After  use,  or,  what  is 
decidedly  better,  just  previous  to  being  used,  they  should  be  either 
boiled  or  scalded  with  boiling  water,  preferably  the  former. 

The  nursing-bottles  should  have  rounded  bottoms,  so  that  there 
are  no  corners  for  holding  dirt,  and  also  that  they  can  not  be  stood 
about  the  room.     If  only  one  or  two  bottles  are  used,  they  should  be 

1  New  York  Medical  Journal,  March  12,  1898. 


296  INFANT  FEEDING 

scalded  after  each  feeding  and  filled  either  with  boric  acid  or  sodium 
bicarbonate  solution,  made  by  adding  a  teaspoonful  of  either  drug 
to  a  pint  of  water.  When  the  bottle  is  to  be  used  again,  the  solution 
should  be  poured  out  and  the  bottle  rinsed  with  plain  sterile  water. 

The  nipples  should  be  of  the  ordinary  short  black-rubber  variety. 
White  nipples,  which  are  said  to  contain  lead,  as  well  as  all  com- 
plicated nipples  and  tubes,  should  be  avoided.  These  latter  can  not 
be  kept  clean,  and  are  a  source  of  infection  in  diarrhea.  In  some 
cities  their  sale  is  prohibited  by  law.  After  each  feeding  the  nipple 
should  be  washed,  turning  it  inside  out  to  do  this  thoroughly,  and 
then  placed  in  a  glass  of  boric  acid  solution  (o.i:Oj).  It  is  a  good 
plan  to  have  several  nipples  on  hand  and  to  boil  them  before  using 
them  for  the  first  time,  and  then  for  five  minutes  every  day.  The  hole 
or  holes  in  the  nipple  should  be  just  large  enough  to  allow  the  milk 
to  drop  out  somewhat  rapidly.  It  should  not  flow  out  in  a  stream. 
If  the  holes  are  too  small,  they  may  be  enlarged  or  new  ones  made  by 
using  a  red  hot  darning-needle.  Some  nipples  are  made  without  holes, 
and  these  may  be  perforated  in  the  same  manner.  When  several 
holes  are  so  made  in  a  nipple,  the  milk  may  not  drop  very  fast,  but 
the  food  reaches  the  child  rapidly  enough,  a  fact  that  may  easily  be 
demonstrated  if  the  nipple  is  grasped  between  the  fingers  and  sucking 
movements  imitated. 

Preparation, — It  is  best  to  prepare  the  entire  quantity  for  twenty- 
four  hours  at  one  time.  If  the  weather  is  warm,  the  milk  must  be 
Pasteurized  or  sterilized  immediately  (see  section  on  Milk)  unless  the 
weather  is  cold  and  a  clean  milk  can  be  obtained. 

If  the  top-milk  method  is  used,  the  milk  should  be  received  in 
bottles.  In  all  cities  there  are  reliable  dairies  that  supply  milk  in 
bottles.  Where  this  is  not  the  case,  the  bottles  should  be  furnished 
the  milkman,  and  arrangements  can  generally  be  made  by  which  the 
milk  will  be  poured  into  them  as  soon  as  possible  after  milking. 
After  the  milk  has  stood  for  at  least  five  hours,  the  first  ounce  of 
cream  may  be  removed  w^th  a  spoon  and  the  remainder  of  the  upper 
one-third  or  one-half,  as  the  case  may  be,  with  a  Chapin  milk-dipper. 
Another  method  is  to  use  a  bent  glass  tube  and  siphon  off  the  lower 
part  of  the  milk  from  the  bottom  of  the  bottle,  or  the  top-milk  may 
be  poured  off  with  reasonable  accuracy. 

The  physician  should  always  write  out  the  quantities  to  be  used 
for  preparing  the  milk.  The  milk-  or  cane-sugar  is  dissolved  in  hot 
water.  Care  should  be  taken  to  use  a  sugar  that  gives  a  clear  solution 
without  filtering.  If  the  solution  is  not  clear,  however,  it  should  be 
filtered  through  a  wad  of  cotton  placed  in  the  bottom  of  a  funnel  or 
through  a  piece  of  druggist's  filter-paper.  This  solution,  together 
with  the  lime-water  or  sodium  bicarbonate,  should  be  poured  into  a 
pitcher.  Into  this  the  milk,  or  milk  and  cream,  should  be  poured, 
and  the  remainder  of  the  water  added.     The  water  should  always  be 


MILK  MODIFICATION  2i)7 

boiled.  The  mixture  should  theu  be  stirred  aud  poured  into  the 
uursiiig-bottles.  The  bottles  should  theu  be  stoppered  with  moder- 
ately tight  plugs  of  non-absorbent  cotton,  to  keep  out  bacteria.  The 
bottles  are  then  Pasteurized  or  sterilized  and  placed  in  a  refrigerator. 
At  the  feeding  hour  the  bottle  is  taken  out  of  the  refrigerator, 
placed  in  a  pitcher  or  tall  vessel  of  hot  water  to  warm  it,  the  cotton 
plug  removed,  and  a  nipple  substituted.  The  milk  should  be  heated 
until  it  is  lukewarm — about  98°-99°  F.  The  nipple  should  never  be 
placed  in  the  mouth  to  test  the  heat,  but  the  milk  may  be  allowed  to 
drop  on  the  wrist,  where  it  should  feel  warm,  but  not  hot, 

OTHER  FOODS  FOR  INFANTS 

The  following  foods  may  be  of  service  in  some  conditions  aJid  may 
be  briefly  considered : 

Condensed  Milk. — This  is  most  useful  iu  many  cases  .as  a  tem- 
porary expedient.  It  may  be  used  to  great  advantage  in  certain 
difficult  ca.ses,  especially  those  which  have  been  improperly  fed  on 
too  high  fat  and  protein  mixtures.  It  is  also  useful  at  times  in 
infants  who  are  not  gaining,  and  when  the  failure  to  gain  is  the  only 
symptom.  As  a  temporary  feeding  when  pure  milk  cannot  be  ob- 
tained, as  in  traveling,  it  may  be  used  to  advantage. 

AVe  generally  use  it  in  dilutions  of  1  in  16,  1  in  12,  or  1  in  8 — 
occasionally  as  high  as  1  in  6.  It  should  be  measured  in  a  measuring 
glass,  otherwise  too  much  will  be  used.  It  may  be  diluted  with  plain 
boiled  water  or,  if  desired,  with  a  thin  cereal  gruel. 

Cream  may  be  added  later  or  olive  oil  may  be  given  in  addition. 
Orange-juice  should  always  be  given  every  other  day  or  every  day 
as  an  antiscorbutic.  If  condensed  milk  feeding  is  continued  too  long, 
anemia,  scurvey,  or  rickets  is  liable  to  develop,  if  not  that,  the  child 
becomes  large  and  flabby,  biit  with  small  bones  and  muscles  and  but 
little  resistance  to  infections. 

Condensed  milk  furnishes  about  100  calories  per  ounce.  In  the 
dilutions  as  ordinarily  used  it  contains  the  following  percentages: 

1  in  6. 
rareh  used. 

Fat     1.66 

Protein    1.50 

Sugar     8.83 

Calories  per  ounce  approximate....    17.00 

Buttermilk. — For  many  years  buttermilk  has  been  used  in  Holland 
for  infant  feeding,  and  of  recent  years  it  has  been  extensively  used 
in  various  countries.  It  has  several  advantages,  chief  of  which  are 
That  it  contains  a  low  fat-  and  sugar-content  and  also  lactic-acid 
bacilli  in  larger  numbers.  The  curd  of  the  milk  is  precipitated  in 
small  flakes.     It  is  easily  digested  by  most  infants  and  may  be  diluted 


1  in  S. 

:  in  12. 

1  in  16. 

1.2.5 

0.S3 

0.62 

1.12 

0.75 

0.56 

663 

4.41 

3.31 

12.8 

8.5 

6.4 

298  INFANT  FEEDING 

with  water  or  cereal  gruels  as  desired.  Sugar  may  be  added,  if  de- 
sired, as  to  any  milk  mixtures.  In  cases  where  the  digestive  faculties 
have  been  impaired  by  feeding  mixtures  containing  too  much  fat 
it  seems  to  be  of  especial  value.  It  is  also  very  useful  in  diarrheal 
affections,  especially  those  in  which  abnormal  bacteria  have  found 
their  way  into  the  intestine.  The  lactic-acid  bacilli  drives  out  most 
of  the  other  intestinal  bacteria.  In  intestinal  indigestion  it  is  often 
of  great  value. 

The  buttermilk  is  best  kept  and  the  mixtures  made  just  before  th«,y 
are  used. 

Acid  Milks. — These  are  extensively  used,  and  are  whole  milk,  to 
which  various  strains  of  lactic-acid  bacilli  have  been  added.  These 
milks  are  sold  under  various  names,  and  often  other  food  substances 
are  incorporated.  Such  acid  milk  contains  fat  in  the  proportion 
as  ordinarily-  found  in  cows'  milk,  and  in  some  cases  may  not  be  as 
desirable  as  buttermilk.  In  other  cases  where  a  very  nutritious  food 
is  needed  they  are  of  great  value.  In  intestinal  indigestion  acid 
milk  is  particularly  useful,  and  it  is  also  of  service  in  the  convales- 
cence from  diarrheal  diseases.  It  should  be  diluted  to  meet  the 
individual  case.  It  is  a  good  plan  to  start  with  rather  weak  mix- 
tures. 

Kumiss  and  other  fermented  milks  are  sometimes  of  use  in  very 
difficult  cases. 

Albumin  Milk. — This  is  a  mixture  suggested  by  Finkelstein  under 
the  name  of  Eiweiss  Milch,  and  has  also  been  called  protein  milk. 
This  food  is  prepared  as  follows:  Heat  one  f(uart  of  whole  milk  to 
100°  F.,  add  four  teaspoonfuls  of  essence  of  pepsin,  and  stir.  Then 
let  the  mixture  stand  at  100''  F.  until  the  curd  has  formed.  Put  the 
mass  in  a  linen  cloth  and  strain  the  whey  from  the  curd.  Remove 
the  curd  from  the  cloth  and  press  it  through  a  fine  sieve  two  or  three 
times,  using  a  wooden  mallet  or  spoon.  While  doing  this  one  pint 
of  water  should  be  added.  The  precipitate  should  be  very  finely 
divided  and  the  mixture  should  look  like  milk.  To  this  one  pint 
of  buttermilk  is  added.  The  buttermilk  contains  little  sugar  and  has 
the  advantage  of  containing  lactic  acid.  The  composition  of  albumin 
milk  is  as  follows: 

Fat    2.5  per  cent. 

Protein     3.0 

Sugar    l.i")         '■ 

Salts      0..5 

One  liter  or  quart  furnishes  about  370  calories.  To  obtain  good 
results  from  this  milk  it  must  be  used  in  a  certain  way.  In  the 
beginning  it  must  not  be  mixed  with  any  other  form  of  food,  not 
even  human  milk  The  infant  should  be  starved  or  given  a  "tea 
diet."     Small  amounts  of  albumin  milk  are  given,  and  if  all  goes 


MILK  MODIFICATION^  299 

well,  lar<ier  and  larger  amounts.  The  yreen,  loose,  bad  stools  should 
qnickly  change  to  soap  stools,  and  then  some  form  of  carbohydrate 
should  be  added  to  increase  the  caloric  value  of  the  food.  Walt 
sugar  is  usually  added,  beginning  with  1  per  cent.,  which  is  sometimes 
added  from  the  beginning.  Some  of  the  mixtures  of  maltose  and 
dextrin  may  be  used  instead. 

There  is  an  initial  loss  of  weight,  owing  to  the  low  caloric  value 
of  the  food,  then  a  stationary  weight,  and  when  the  carbohydrate  is 
added  there  should  be  a  gain.  Too  long  a  period  should  not  elapse 
between  beginning  the  milk  and  adding  the  carbohydrate.  The  dex- 
tri-maltose  may  be  added  up  to  5  per  cent.,  and  if  there  is  no  gain, 
2  per  cent,  of  some  cereal  tlour  may  be  added. 

Albumin  milk  is  a  very  valuable  addition  to  the  armamentarium 
of  the  pediatrician.  It  is  difficult  to  make,  and  for  this  reason  can- 
not always  be  used  in  the  cases  where  it  would  do  the  most  good.  A 
full  account  by  Hess  will  be  found  in  the  American  Journal  of  the 
Diseases  of  Children,  December,  1911,  vol.  ii.,  p.  422. 

For  those  who  cannot  afford  casein  milk  Reuben  suggests  the  fol- 
lowing: Add  two  junket  tablets  to  a  pint  of  milk.  After  standing 
for  one-half  hour  strain,  discard  the  whej''  and  rub  the  curd  through 
a  fine  sieve  together  with  a  pint  of  milk  and  then  add  enough  plain 
boiled  water  to  make  one  quart.  The  whole  mixture  is  then  brought 
to  a  boil  with  constant  stirring  and  is  then  ready  for  use.  This  has 
nearly  the  value  of  casein,  but  lacks  the  acidity,  a  point  which  does 
not  seem  to  be  essential. 

Albumin  milk  furnishes  a  food  high  in  protein,  but  apparently 
this  does  not  harm  the  infant  during  the  short  period  that  it  is 
taken,  but  helps  make  up  the  previous  loss.  The  calorie  value  is  low 
and  there  may  be  a  loss  of  weight,  but  not  at  the  expense  of  the 
body  protein.  The  total  aciditj',  the  volatile  and  fatty  acids  of  the 
stools  are  decreased  and  the  amount  of  water  lost  through  the  bowel 
is  lessened  while  mineral  salts  are  retained  better.  There  is  an  in- 
crease in  the  formation  of  soap  with  a  tendency  to  fewer  and  less 
irritating  movements.  The  food  should  only  be  used  for  short  periods 
as  a  corrective  of  digestion  or  nutritional  disturbances. 

It  is  indicated  in  diarrheal  diseases  and  indigestion  and  various 
forms  of  nutritional  disturbances,  as  marasmus,  and  where  the  toler- 
ance for  sugar,  fat,  or  salts  has  been  disturbed. 

Dry  preparations  to  be  mixed  with  milk  have  been  manufactured 
to  take  the  place  of  casein  milk.  These  are  known  as  calcium-casein 
or  Larosan.     The  preparation  of  the  mixture  is  as  follows: 

In  about  %  of  a  pint  of  milk  dissolve  %  ounce  of  casein-calcium 
milk ;  in  the  meantime  heat  %  of  a  pint  of  milk,  mix  the  cold  solution 
of  casein-calcium  milk  with  the  hot  milk,  boil  the  whole  five  minutes, 
stirring  constantly;  this  makes  a   smooth  homogeneous  mixture  of 


300  INFANT  FEEDING 

thin  cream  consistency ;  to  this  add  one  pint  of  boiled  water  or  cereal 
decoction. 

This  has  the  following  composition:  protein  3.4  per  cent,,  fat,  1.7 
per  cent.,  sugar,  2.2  per  cent.,  PoO.,,  .12  per  cent.,  CaO,  .13  per  cent. 
It  is  to  be  used  like  casein  milk  and  dextromaltose  added  in  the  same 
way  after  the  first  few  days. 

Mammala. — A  dried  milk  made  by  the  Hatmaker  process  and 
marketed  under  various  names  in  different  countries,  is  a  useful  food 
in  infants  with  weak  di^jestions  and  especially  when  coupled  witji 
ability  to  retain  but  small  quantities.  It  is  also  useful  in  traveling 
and  after  digestive  disturbances  and  during  convalescence,  and  where 
cows'  milk  cannot  be  digested  as  ordinarily  given.  It  is  said  to  have 
a  value  of  127  calories  per  ounce,  or  about  4.2  calories  per  gram 
and  a  heaping  teaspoonful  weighs  about  5  grams.  Its  approximate 
composition  is  said  to  be : 

Protein    24  per  cent. 

Butter    fat     12     ••       •' 

Milk    sugar    54     "       " 

Milk    salts    5     "       " 

Moisture      5     "       " 

100  per  cent. 

One  heaping  teaspoonful  to  each  ounce  of  water  for  the  smaller 
babies  and  somewhat  more  for  the  larger  ones  will  usually  suffice. 
It  is  better  to  weigh  the  powder  and  measure  the  water.  In  very 
hot  weather  give  somewhat  more  water  or  if  there  is  constipation, 
orange-juice  should  be  given  daily  or  once  or  twice  a  week. 

The  label  contains  the  following  suggestions  as  to  quantities: 

Cubic  No.  of  No.  of 

Grams          centi-        heaping      teaspoon-  Total 

of           metres  of   teaspoon-       fuls  of      No.  of  Quantity 

PERIOD.                   MAMMALA    Warm        fuls  of          Warm    Feedings  of 

per            W.itor  MAMMALA     Water    per  day.  MAMMALA 

^^—                           Feeding.          per              per               per  per  day. 


per 

per 

per 

Feeding. 

Feeding. 

Feeding 

20 



4 

30 

1 

6 

42 

H 

9 

48 

u 

10 

54 

2 

11 

Day  of  birth    

2nd   dav     5  30  1  6  S  40    Grams 

3d    dav     7  42  l^  9  8  56 

4th   daV    8  48  U  10  8  64 

5th  day    9  54  2  11  8  72 

While    the    baby's    weight 

is   less  than   7   pounds..    11  66  2  13 

While    the    baby's    weight 

is  between: 
7  and     8    pounds    12 


8  ' 

9 

9  ' 

10 

10  • 

11 

11  ' 

12 

12  ' 

13 

13  ' 

14 

12 

72 

2J 

14 

8 

96 

13 

78 

2i 

15 

8 

104 

15 

90 

3 

18 

8 

120 

17 

102 

31 

20 

8 

136 

19 

114 

4 

23 

8 

152 

24 

144 

5 

29 

7 

168 

25 

150 

5 

30 

7 

175 

AIILK  MODIFICATIO\ 


301 


PERIOD. 

Grams 

of 

MAMMALj^ 

per 

Feeding. 

Cubic 
centi- 
metres of 
Warm 
Water 
per 
Feeding. 

No.  of 

heaping 

teaspoon- 

fuls  of 

MAMMALA 

per 

Feeding. 

No.  of 

teaspoon 

fuls  of 

Warm 

Water 

per 

Feeding. 

No.  of 
Feedings 
per  day. 

Total 

Quantity 

of 

MAMMALA 

per  day. 

14 

••      15 

26 

i.->o 

5 

30 

7 

182 

15 

••      16 

27 

150 

5.V 

30 

7 

189 

16 

•      17 

32 

160 

6 

32 

U 

192 

17 

"      18 

33 

165 

6  A 

33 

G 

198 

18 

••      20 

35 

175 

7 

35 

6 

210 

20 

•      22 

37 

185 

7i 

37 

6 

222 

22 

■      24 

40 

200 

8 

40 

6 

240 

24 

••      26 

50 

250 

10 

50 

5 

250 

Geiatin. — In  chronic  intestinal  infections,  accompanied  with  food 
decomposition,  gelatin  is  sometimes  of  great  benefit.  Some  of  the 
putrefactive  organisms  will  not  grow  on  gelatin.  One  ounce,  which 
yields  about  120  calories,  may  be  given  to  a  child  in  twenty-four  hours. 
It  may  be  mixed  with  milk  or  given  as  a  jell.v.  Sugar-free  milk  will 
be  found  to  be  useful  with  this. 

Standardized  Gruels. — Chapin  has  suggested  using  gruels  of  defi- 
nite strength,  so  that  one  may  know  the  value  of  food  given  as  gruel, 
and  also  the  percentages  of  the  various  elements.  He  determined 
that  the  weight  of  the  various  measures  of  different  cereals  were  as 
follows : 

1  level  tablespoonful  of  pearl  barley  weighs  J  ounce  avoirdupois. 


((                      (I 

barlev  flour 

(c                        te 

wheat   flour 

"                       " 

rolled  oats 

ounce  dipper  of 

pearl  barley 

"             " 

barlev    flour 

ee                  « 

wheat   flour 

sc                  te 

rolled   oats 

The  percentage  of  various  food  components  in  gruels  will  be  found 
to  be  approximately  as  follows: 


Pearl  barley. 


Barley  flour. 


Wheat. 


Rolled  oats. 


fl, 

o 

a. 

z> 

2_. 

o 

X, 

o 

1   oz. 

to  quart   . . 

.   0.14 

1.34 

0.195 

2.093 

0.331 

2.161 

0.262 

1.669 

2  ozs 

to  quart    . 

.    0.28 

2.68 

0.390 

4.186 

0.662 

4.322 

0.524 

3.338 

3     " 

" 

0.585 

6.279 

0.993 

6.483 

0.786 

5.007 

4     " 

ce 

0.780 

8.372 

1.324 

8.644 

1.048 

6.676 

5     " 

" 

0.975 

10.465 

1.655 

10.805 

1.310 

8.345 

6     " 

1.170 

10.558 

1.986 

12.960 

1.572 

10.014 

7     " 

" 

1.365 

14.651 

2.317 

15.127 

1.834 

11.683 

8     " 

" 

1.560 

16.744 

2.648 

17.288 

2.096 

13.352 

Plain  gruels  cannot  be  made  much  stronger  than  2  ounces  to  the 
quart. 


302  INFANT  FEEDING 

Dextrjnized  gruels  may  be  made  up  to  as  high  as  8  ounces  to  the 
quart. 

Another  method  is  to  use  cereal  flours.  The  percentages  furnished 
by  these  flours  will  be  found  under  the  heading  of  Farinaceous  Gruels 
in  the  first  part  of  this  volume.  The  cereal  flours  are,  as  a  rule,  very 
much  better,  as  they  make  a  smoother  gruel  and  require  much  less 
cooking,  fifteen  to  twenty  minutes  giving  as  satisfactory  a  gruel  as 
boiling  rice  or  barley  grains  for  three  or  four  hours.  The  cereal 
gruels  are  very  useful  in  modifying  milk,  and  they  may  also  be  used 
alone  in  various  diseases  of  the  stomach  and  intestine.  As  they  gen- 
erally do  not  cause  fermentation  they  are  of  great  value  in  some  forms 
of  diarrhea. 

Oatmeal  is  of  use  in  constipation,  and  the  others  are  of  value  in 
diarrheas.     Corn-meal  gruels  are  valuable  in  the  underfed. 

The  cereal  flours  contain  about  100  calories  to  the  ounce,  and  the 
underfeeding  which  occurs  when  a  thin  gruel  is  used  is  very  ap- 
parent. 

The  Soy  Bean. — In  certain  conditions  the  soy  bean  (see  same  and 
Diabetes)  is  of  great  value.  In  eases  when  milk  is  badly  borne,  in 
certain  forms  of  intestinal  disorders,  in  diarrhea,  and  especially  in 
the  convalescence  after  diarrhea,  in  certain  cases  of  marasmus  and 
in  malnutrition,  the  soy  bean  flour,  properly  used,  is  of  great  value. 

Each  ounce  contains  13  grams  protein  and  120  calories. 

Protein.  Fat.  Sugar.      Calories. 

Percent.        Percent.        Percent.    Percent. 

i  ounce,  1   level  tablesponful   to  quart    ....  0.35  0.15  0.08  30 

J       •'        2      "      tablespoonfuls          "        ....  0.70  0.30  0.15  60 

I       "        3      "                   "                     "        10  0.45  0.23  90 

1  ounce    to    quart    1.4  0.60  0.30  120 

2  ounces    to    quart    2.80  1.20  0.60  240 

3  "  "  4.20  1.80  0.90  300 

4  "  "  5.60  2.^0  1.20  480 

5  "  "  7.00  3.00  1.50  600 

6  "  "  8.40  3.60  1.80  720 

7  "  "  9.80  4.20  2.10  840 

8  "  "  11.00  4.80  2.40  900 

A  quart  of  gruel  is  made  by  boiling  from  1  level  tablespoonful  to 
6  ounces  of  the  soy  gruel  in  1  quart  of  water  for  fifteen  minutes, 
adding  water  to  make  up  for  loss  by  evaporation.  Salt  should  be 
added  to  taste. 

These  gruels  do  not  thicken  during  cooking,  as  they  contain  no 
starch,  and  readily  settle  on  standing.  This  may  be  overcome  by 
adding  1  to  2  heaping  teaspoonfuls  of  barley,  oat  or  wheat  gruel 
flour  before  cooking,  which  will  add  0.6  per  cent,  to  1.2  per  cent, 
starch  to  the  gruels,  and  also  slightly  increase  the  percentage  of 
protein. 

A  good  standard  grael,  which  may  be  diluted  as  desired,  may  be 
made  by  using  1  ounce  of  soy  bean  flour,  2  ounces  of  barley  flour,  to 


MILK  MODIFICATION'  303 

a  quart  of  water.  This  will  contain  2  per  cent,  protein,  0.60  per 
cent,  fat,  and  5.10  per  cent,  carbohydrate,  with  a  caloric  Value  of 
320  calories  or  10  calories  per  ounce.  This  is  just  half  the  value  of 
milk.  It  maj^  be  further  increased  by  adding  an  ounce  of  sugar, 
which  brings  it  up  to  about  430,  and  the  yolk  of  one  egg  will  add 
55  calories  more,  or  cream  may  be  added,  each  ounce  increasing  the 
food  value  about  50  calories.  About  one  ounce  and  a  half  of  this 
to  each  pound  of  the  babies'  weight  will  about  cover  the  caloric  needs 
of  the  baby.  Without  the  cream  or  egg  it  will  require  about  four 
ounces  per  pound  of  body-weight.  As  this  is  more  than  can  be 
given  to  advantage  it  should  be  remembered  that  the  soy  gruel  should 
not  be  kept  up  unless  the  food-value  is  enhanced.  This  may  often  be 
done  to  advantage  by  adding  condensed  milk  or  cows'  milk  to  the 
gruel.  This  standard  gruel,  or  a  weaker  one,  may  be  used  to  dilute 
milk  to  advantage  in  cases  of  marasmus.  The  infants'  stools  should 
be  somewhat  brownish  in  color,  like  malted-milk  stools.  If  the  gruels 
are  used  too  strong  to  begin  with,  the  stools  will  be  foul  smelling 
and  generally  thin.  The  bean  should  be  withdrawn  and  barley  or 
other  cereal  gruels  given,  and  when  the  bean  is  added  again  it  should 
be  done  gradually.  Edsall  and  Miller  have  experimented  with  a 
bean  flour,  in  which  the  starch  is  predigested  by  means  of  a  diastasic 
ferment.  They  have  found  it  useful  in  digestive  disturbances  and 
malnutrition. 

Vegetable  Broths. — Mery  recommends  the  use  of  the  following 
vegetable  broth  as  a  substitute  for  milk  after  gastro-enteritis : 

Potatoes    60  grams. 

Carrots     4.5       " 

Turnips     15       " 

Dried  peas  6       " 

Dried   beans 6       " 

Water     1000       " 

Boil  in  a  covered  earthen  pot  for  four  hours,  strain  and  add  water 
to  make  1  liter,  and  5  grams  of  salt. 

Vegetable  Purees. — In  infants  who  are  not  gaining  and  in  cases 
of  constipation  and  in  some  other  nutritional  disturbances,  as  well  as 
for  the  healthy  infant,  we  have  found  the  following  vegetable  puree 
to  be  of  great  value: 

A  mixture  is  made  of  any  sort  of  vegetable  available — potatoes, 
carrots,  beets,  turnips,  greens  of  any  kind — in  fact  any  vegetable 
whatever  except  those  that  are  highly  flavored  or  contain  aromatics. 
Naturally  radishes,  onions,  green  peppers,  cucumbers  and  the  like 
should  not  be  thought  of  in  this  connection.  The  vegetable  so  selected 
should  be  thoroughly  washed  and  then  cut  up  or  chopped  into  small 
pieces  not  larger  than  a  quarter  of  an  inch  in  diameter,  and  if  a  good 
mill  is  at  hand  they  may  be  run  through  that  to  advantage.  They 
are  then  covered  with  sufficient  water  and  placed  on  the  stove  and 
allowed  to  cook  very  thoroughly.     Additional  water  may  be  added 


304  INFANT  FEEDING 

from  time  to  time  and  the  surface  skimmed  as  may  be  necessary. 
The  water  in  which  the  vegetables  are  cooked  is  to  be  utilized  and 
care  should  be  taken  that  it  is  not  thrown  away.  The  material  is 
then  passed  through  a  sieve  and  all  the  coarse  particles  discarded 
and,  if  necessary,  the  resulting  mass  cooked  again  until  it  is  as  thick 
as  an  ordinary  thick  soup.  This,  in  a  sterile  vessel  placed  in  the 
ice  box,  keeps  very  well,  and  from  one-quarter  to  a  tablespoonful  may 
be  used  according  to  the  age  of  the  child  and  the  nature  of  the  dis- 
turbance for  which  it  is  given.  It  may  be  added  to  milk  or  to  broths 
or  served  over  cereals. 

Olive  Oil. — This  is  most  useful  where  cream  disagrees  and  where 
it  is  imperative  to  supply  nourishment.  It  is  sometimes  of  service 
in  constipation  in  thin  infants.  From  one  to  four  teaspoonfuls  may 
be  given  daily.  We  begin  with  one-quarter  teaspoonful  once  or  twice 
a  day  after  feeding,  and  increase  one  dose  a  day  until  this  amount 
is  given  after  every  feeding.  It  may  then  be  increased  to  half  a 
teaspoonful  at  a  dose  if  thought  advisable.  One-quarter  to  one-half 
ounce  a  day  is  as  much  as  it  is  advisable  to  use  in  young  infants. 
Older  ones  may  take  somewhat  more.  Olive  oil  furnishes  245.5 
calories  per  ounce  by  volume. 

Homogenized  Oil  Mixtures. — By  using  a  machine  which  drives 
oils  or  mixtures  containing  them  through  a  fine  agate  valve  against  a 
pressure  of  from  3000  to  5000  pounds  to  the  square  inch  emulsions 
of  oils  may  be  obtained  that  are  homogeneous,  that  is,  they  will  not 
separate  on  standing.  Ladd  has  used  olive  oil  and  milk  mixtures 
treated  in  this  way  with  considerable  success  in  infant  feeding.  The 
very  finely  divided  oil  being  more  easily  digested  than  the  coarser 
emulsions. 

Malted  Milk. — This  is  valuable  food  in  certain  conditions.  It 
may  be  used  temporarily  when  pure  milk  cannot  be  obtained  and  in 
traveling. 

In  some  digestive  disturbances  it  is  also  useful.  It  may  also  be 
added  to  milk  mixtures. 

The  composition  of  Horliek's  malted  milk  is — 

Fats    878 

Protein     16.35 

Dextrin     18.80 

Lactose  and   maltose    49.15 

(Total  soluble  carbohydrates  67.95.) 

Inorganic  salts   3.86 

Moisture     3.06 

It  is  low  in  fats  and  high  in  sugars.  Per  ounce  dry  it  has  a  food- 
value  of  about  127  calories.  One  ounce  in  8  ounces  of  water  makes 
a  mixture  containing  approximately  1  per  cent,  fat,  2  per  cent,  pro- 
tein, and  8.5  per  cent,  sugar.  The  caloric  needs  of  the  infant  are 
easily  covered  in  the  solutions  ordinarily  used,  but  for  continuous 
use  has  much  the  same  objections  as  condensed  milk.     If  used  over 


MILK  MODIFICATION  305 

considerable  periods,  orange-juice  or  other  fresh  fruit-juice  must  be 
given,  and  fat  either  as  cream  or  olive  oil.  When  cream  or  olive  oil 
is  given  a  little  less  milk  may  generally  be  used. 

Malt  Soups. — The  idea  of  using  malted  foods  was  first  published 
by  Liebig  in  1863.  He  endeavored  to  prepare  a  food  that  should  be 
chemically  and  physiologically  correct.  Keller  in  1898  modified  the 
Liebig  formula,  and  his  method  was  as  follows:  50  grams  (2  ounces) 
of  wheat  flour  to  Ys  liter,  (11  ounces)  of  milk,  with  constant  stirring. 
In  a  second  vessel  100  grams  of  malt-soup  extract  or  malt  extract, 
with  the  addition  of  10  c.c.  (21/2  drams)  of  a  10  per  cent,  solution 
of  potassium  carbonate,  are  dissolved  in  %  liter  (20  ounces)  water 
at  120°  F.  The  mixtures  are  then  mixed  and  boiled  for  three  or  five 
minutes.     This  is  said  to  contain — 

Protein     2      per  cent. 

Fat    1.2 

Carbohydrate    (maltose)     12.1  " 

The  caloric  value  is  808  calories  per  liter,  or  somewhat  more  than 
either  mothers'  or  cows'  milk. 

This  may  be  diluted  with  water  as  desired,  and  approximately  the 
same  dilutions  as  made  with  cows'  milk  may  be  used.  Cream  may  be 
added  if  desired,  but,  as  a  matter  of  fact,  the  cases  in  which  the  food 
is  indicated  do  not,  as  a  rule,  bear  the  addition  of  much  fat. 

A  preparation  of  maltose  and  potassium  carbonate,  Loefland's 
malt-soup  extract,  is  much  used,  as  it  simplifies  the  measuring. 
Any  thick  malt  extract  with  the  potassium  carbonate  (not  bicarbonate) 
may  be  used.  The  bicarbonate  is  liable  to  cause  vomiting.  Maltose 
often  causes  diarrhea,  and  the  flour  added  usually  counteracts  this. 

Dry  malt  soup  stock  may  also  be  had  and  this  simplifies  the  prepa- 
ration of  malt  soup  mixtures. 

Malted  Gruels. — Malted  gruels  are  advocated  by  some,  especially 
in  preparing  milk  for  infants  with  weak  digestion.  They  are  pre- 
pared in  the  following  manner :  A  tablespoonful  of  barley  flour  or 
of  any  other  flour  desired  is  boiled  in  a  little  more  than  a  pint  of 
water  for  fifteen  minutes.  As  soon  as  it  has  cooled  a  teaspoonful  of 
a  good  malt  extract  or  a  teaspoonful  of  diastase  is  added.  This  mix- 
ture is  stirred  thoroughly,  and  may  then  be  used  in  the  place  of 
ordinary  barlej'-water.  Diastase  preparations  are  made  by  most  of 
the  leading  manufacturing  chemists.  Diastoid,  made  b}^  the  firm  of 
Horlock,  maltine,  and  diazyme  are  preparations  of  this  class.  The 
thick  malt  extracts  are  sometimes  given  to  infants  just  before  a 
feeding.  Of  these,  several  doses  may  be  given  daily  for  indigestion 
and  constipation. 

Chapin  suggests  that  a  home-made  decoction  of  malt  be  used  in 
making  malted  gruel.  His  directions  are  as  follows:  "A  tablespoon- 
ful of  malted  barley  grains  is  put  in  a  cup,  and  enough  cold  water 
added  to  cover  it — usually  two  tablespoonfuls — as  the  malt  quickly 
20 


306  INFANT  FEEDING 

absorbs  some  of  the  water.  This  is  prepared  in  the  evening  and  placed 
in  a  refrigerator  overnight.  In  the  morning  the  water,  looking  like 
thin  tea,  is  removed  with  a  spoon  or  skimmed  off,  and  is  ready  for 
use.  About  a  tablespoonful  of  this  solution  can  be  secured  and  is 
very  active  in  diastase.  It  is  sufficient  to  dextrinize  a  pint  of  gruel 
in  ten  to  fifteen  minutes.  This  should  be  prepared  fresh  every 
day." 

FEEDING  DURING  THE  SECOND  YEAR 

During  the  second  year  of  life  as  much  care  is  required  in  feeding 
as  during  the  first.  The  fear  -of  the  second  summer  would  largely 
be  overcome  if  the  child  were  not  allowed  to  eat  food  unsuited  to  its 
digestion.  The  fact  that  some  children  thrive  on  almost  any  kind 
of  food  is  no  excuse  for  permitting  a  child  to  have  the  same  food 
as  its  elders,,  as  is  so  often  done.  Most  of  the  illness  and  many  of 
the  deaths  of  childhood  are  traceable  to  improper  diet. 

During  the  second  year  milk  should  form  the  basis  of  the  diet. 
In  cities  or  where  the  milk-supply  is  not  above  suspicion,  it  is  best 
to  Pasteurize  the  milk  until  the  second  summer  has  been  passed,  or 
even  longer  if  circumstances  warrant.  As  a  rule,  the  milk  requires 
but  little  modification,  and  after  the  thirteenth  month,  and  often 
before,  may  generally  be  taken  unmodified.  As  the  child  is  now  able 
to  digest  starchy  food,  milk-sugar  may  be  omitted.  In  cases  where 
the  milk  is  not  thoroughly  digested,  as  is  evidenced  by  curds  in  the 
stools,  lime-water  may  be  used,  and  may  be  added  in  quantities  of 
from  5  to  10  per  cent.,  or  even  more  if  necessary.  If  the  milk  is  very 
rich,  it  should  be  diluted  either  with  lime-water  or  usually  with  plain 
sterile  water — three  parts  of  milk  to  one  of  water.  If  the  milk  is 
poor,  or  if  milk  that  is  not  rich  does  not  agree  with  the  child,  it  may 
be  prepared  as  follows:  Fill  a  glass  three-quarters  full  of  milk,  add 
one  or  two  tablespoonfuls  of  cream,  and  fill  to  the  top  with  plain 
water.  If  this  does  not  answer,  add  a  tablespoonful  of  lime-water. 
During  illness  and  often  under  other  circumstances  the  alkaline  car- 
bonated waters  will  be  found  useful  for  diluting  the  milk.  If  the 
milk  is  poor,  another  plan  is  to  use  the  upper  two-thirds  of  the 
milk. 

Starchy  food  may  be  given  in  the  form  of  gruel,  either  alone  or, 
what  is  better,  mixed  with  the  milk.  Barley-gruel  or,  if  there  is  a 
tendencj^  to  constipation,  oatmeal-gruel  is  added,  one-fifth  or  one- 
fourth  part  of  gruel  being  added  to  each  feeding.  The  gruel  should 
be  freshly  prepared  and  mixed  immediately  with  the  milk.  A  pinch 
of  salt  and  a  very  small  quantity  of  cane-sugar  may  be  added  to 
render  it  more  palatable.  It  may  then  be  Pasteurized  like  ordinary 
milk. 

During  the  second  year  three  to  five  meals  should  be  given.  The 
bottle  should  be  dispensed  with,  and  the  food  be  taken  from  a  cup  or 


FEEDiyO  DURING  THE  SECOl^D  YEAR  307 

spoon.  If  the  bottle  is  not  taken  from  the  child  early,  it  may  be 
clitHeult  to  break  it  of  the  bottle  habit.  The  following  diet-lists  for 
ditferent  ages  will  be  found  useful : 

Tivelve  to  Fifteen  Months. — Foods  Allowed.  Milk  and  dishes  made 
out  of  milk.  If  whole  milk  does  not  agree,  it  may  be  boiled,  diluted 
wnth  a  cereal  water  or  barley  water,  or  diluted  with  plain  water  or 
lime-water.  Buttermilk,  kumiss,  and  similar  preparations  may  be 
given,  if  desired,  in  place  of  milk.  Junket  and  curd.  Malted  milk  or 
dried  milk  (Mammala).     Cream  and  butter. 

Cereals.  Always  well  cooked,  as  oatmeal,  cracked  wheats  cream 
of  wheat,  wheatena,  rice,  farina,  cornmeal  mush,  hominy,  small 
hominy,  arrowroot,  cornstarch. 

Bread  stuffs,  as  very  stale  bread,  toast,  zwieback,  or  crackers. 
These  may  be  given  dry  or  with  milk. 

Vegetables.  Carrots,  asparagus  tops,  cauliflower  tops  finely  mashed, 
baked  or  mashed  potato,  spinach,  peas  or  string  beans  put  through 
a  sieve  or  finely  milled. 

Fruit  Juice.     Orange  .juice,  strained  apple  sauce,  or  prune  juice. 

Broths.  Chicken,  beef,  or  mutton  broths,  with  cereal  in  it,  or 
thickened  with  flour. 

Coddled  egg  once  or  twice  a  week. 

If  the  child  wakes  early,  either  the  orange  juice  or  milk.  A  break- 
fast of  cereal  and  milk  or  toast  and  milk ;  in  the  middle  of  the  morning 
a  cup  of  milk  and  cracker,  if  desired.  At  dinner  an  egg,  or  a  cup  of 
broth  with  a  piece  of  zwieback  or  toast,  and  milk  after  it  to  satisfy 
the  appetite.  At  supper,  milk  or,  if  very  hungry,  a  little  cereal 
and  milk.  At  10  o'clock  a  bottle  may  occasionally  be  used  to  ad- 
vantage. 

First  Meal.  On  waking  the  child  should  receive  a  cupful  of  warm 
milk,  modified  as  previously  suggested.  If  the  child  is  accustomed 
to  waking  very  early,  more  milk  may  be  given  at  about  7  a.  m.  ; 
otherwise  this  last  may  be  regarded  as  the  first  meal. 

Second  Meal,  10  :30  a.  m.  Eight  ounces  of  warm  milk  and  barley 
gruel. 

Third  Meal,  2  p.  m.     One  of  the  following : 

(a)  eight  ounces  (a  cupful j  of  beef  broth. 

(b)  eight  ounces  (a  cupful)  of  veal  broth. 

(c)  eight  ounces   (a  cupful)   of  mutton  broth. 

(d)  eight  ounces  (a  cupful)  of  chicken  broth. 

(e)  Yolk  of  a  lightly  boiled  egg  with  stale  bread  crumbs. 
Fourth  Meal,  5  p.  m.     Eight  ounces  of  milk  and  barley  gruel. 
Fifth  Meal,  10  p.  m.  (if  required  ).     Eight  ounces  of  milk. 
Orange  juice,  one  or  two  tablespoonfuls  at  a  time,  may  be  given 

one  hour  before  the  10 :30   a.  m.   feeding.     If  there   is   a   tendency 
to  loose  bowels  this  should  be  omitted. 

If  the  child's  appetite  is  very  good  a  small  piece  of  zwieback  may 


308  INFANT  FEEDING 

be  given  with  either  the  second  or  fourth  meal.  This  should  not  be 
soaked  in  the  milk,  but  the  child  should  be  allowed  to  nibble  at  it 
dry. 

Sometimes  shorter  intervals  are  used,  especially  in  children  who 
are  underweight,  or  who  have  been  underfed.  The  following  is  a 
sample  diet: 

Diet  List  for  Child  Twelve  to  Fifteen  Months: 

5  A.M.  Orange  juice,  1  to  2  oz.,  if  awake;  if  not,  give  to  child 
some  time  during  the  twenty-four  hours. 

7  A.  M.  Milk,  8  oz.  Quantity  varied  if  child  is  sick.  In  case  of 
vomiting,  lessen  quantity,  or  even  omit  one  feeding. 

9  A.  M.  Farina  or  cream  of  wheat  or  strained  oatmeal,  1  to  2  table- 
spoonfuls.     (Strain  oatmeal  through  medium-sized  sieve.) 

11  A.  M.     Milk,  8  oz.     Before  midday  nap. 

1  p.  M.     Yolk  of  soft  boiled  egg  with  breadcrumbs ;  custard. 

4  P.M.  Strained  prunes;  milk,  6  oz.  (Boil  prunes  and  strain 
through  medium  sized  sieve.) 

7  p.  M.     Milk,  8  oz. 

(All  these  quantities  must  be  varied  if  the  child  is  sick,  gradually 
increasing  the  amount  as  the  child  gets  well  until  the  amount  for  a 
normal  child  is  attained.) 

A  child  this  age  will  take  10  to  12  oz.  of  water  during  the  twenty- 
four  hours,  between  feedings. 

Fifteen  to  Eighteen  Months. — Same  as  above,  together  with  zwie- 
back, stale  bread  (oven-dried)  ;  whole  eggs  very  soft  boiled;  strained 
oatmeal,  barley  or  wheat  porridge ;  bread  and  milk ;  thin  biscuit 
(crackers)  ;  junket,  custards  and  cornstarch  puddings;  scraped  raw 
beef  or  mutton  in  very  small  quantities,  meat  run  through  a  mill ; 
butter  and  olive  oil,  which  may  be  given  with  meals  if  more  fats  are 
desired  in  the  diet ;  asparagus  tips,  mashed  cauliflower  tops,  strained 
puree  of  peas. 

A  Sample  Diet  for  a  Child  of  Fifteen  to  Eighteen  Months. — Break- 
fast, 7  A.  M.  Either  (a)  two  tablespoonfuls  of  a  cereal  jelly  (oatmeal 
or  other  grain  as  desired),  with  salt  and  two  tablespoonfuls  of  cream, 
and  eight  ounces  of  milk  to  drink;  or  (b)  a  bowl  of  bread  and  milk 
containing  eight  ounces  of  milk  and  a  slice  of  stale  bread. 

Second  Meal,  10 :  30  a.  m.  Milk,  with  a  cracker  or  thin  slice  of 
stale  bread  or  a  piece  of  zwieback. 

Third  Meal,  2  p.m.  One  of  the  following:  (a)  very  soft  boiled 
egg  with  stale  bread  crumbs,  (b)  Eight  ounces  of  broth  (beef,  veal, 
mutton  or  chicken),  with  stale  bread  crumbs  or  a  little  barle^^  added 
to  it.  (c)  A  tablespoonful  of  mashed  or  baked  potato  with  meat  broth 
or  gravy  (one  to  two  ounces),  or  with  two  tablespoonfuls  of  cream. 
I\Iilk  to  drink,  (d)  Scraped  raw  beef  or  mutton,  two  to  three  table- 
spoonfuls on  a  "banquet  wafer"  with  a  cup  of  milk.  A  tablespoon- 
ful of  junket  may  be  added  to  any  of  these.  Supper,  5 :  30  or  6  p.  m. 
Eight  ounces  of  milk  with  a  piece  of  zwieback,  a  slice  of  stale  bread, 


FEEDiyo  DURING  THE  SECOND  YEAR  309 

or  a  cracker  or  two.     Fifth  Meal,  10  p.  m.  (if  needed).     Cup  of  milk. 

Fruit  juice  may  be  given  as  previously  directed.  Eggs  should 
not  be  given  of  toner  than  twice  a  week,  as  children  tire  of  them 
easily. 

Eighteenth  to  Twenty-Fourth  Month. — Add  to  the  above  purees 
run  through  a  sieve  or  made  of  carefully  milled  vegetables.  These 
may  be  made  out  of  fresh  or  dried  peas,  celery,  or  corn  and  the  like. 
Hominy  may  be  given.  Tapioca,  sago,  scraped  raw  apple,  ripe  raw 
peach,  stale  lady-fingers.  Increase  the  meat  in  quantity,  but  only 
once  a  day.  See  that  the  child  has  something  to  chew  on,  crusts  of 
bread  and  the  like.  End  the  meal  with  a  little  fruit  and  not  the 
sweet. 

Two  to  Two  and  One-Half  Years. — Milk  to  be  regarded  as  the 
chief  article  of  diet.  Many  children  have  no  desire  for  other  foods 
until  the  second  or  third  year.  These  children  will  generally  be  found 
to  thrive  on  milk  alone  or  with  slight  additions  to  the  diet.  As  the 
child's  digestive  power  increases,  the  following  articles  may,  how- 
ever, be  added  one  at  a  time : 

Fruit:  juice  of  ripe  fresh  fruit,  that  of  oranges  and  peaches  being 
best.  Ripe  fresh  grapes  skinned  and  seeded.  Baked  apple — pulp 
only,  the  skin  and  seeds  to  be  carefully  removed.  Stewed  prunes,  the 
skins  to  be  removed  by  passing  through  a  sieve. 

Meats :  scraped  raw  beef  or  mutton ;  rare  roast  beef  or  mutton 
pounded  to  a  pulp.  Chicken  or  turkey,  the  lean  white  meat  minced 
to  a  pulp. 

Vegetables :  mashed  baked  potato  with  cream  or  covered  with  gravy 
from  roast  meats.  If  the  latter  is  very  fat  the  fat  should  be  removed 
by  skimming  or  by  means  of  a  piece  of  blotting  paper.  Very  well 
cooked  spinach,  celery  and  cauliflower  tops ;  any  vegetable  that  can 
be  put  through  a  sieve,  as  tender  carrots,  lima  beans  or  peas. 

Cereals:  Well  boiled  rice  and  other  well  cooked  cereals,  already 
mentioned. 

Desserts:  boiled  custard,  milk  and  rice  puddings,  junket. 

Four  meals  will  generally  suffice  after  the  eighteenth  month.  The 
following  dietary  will  serve  as  a  suggestion : 

If  the  child  wakes  early,  a  cupful  of  warm  milk  (six  ounces). 

Breakfast,  7  a.  m.  (a)  four  tablespoonfuls  of  oatmeal  porridge  or 
other  cereal  with  salt  and  two  tablespoonfuls  of  cream,  milk  to  drink. 
(b)  Yolk  of  a  lightlj'  boiled  Qg^  with  salt  and  bread  broken  into  it, 
milk  to  drink. 

Second  Meal,  10 :30  a.  m.  Cup  of  milk  with  two  soda  .biscuits 
(crackers),  slice  of  bread  or  a  piece  of  zwieback. 

Dinner,  2  p.m.  One  of  the  following;  (a)  a  bowl  (eight  ounces) 
of  meat  broth  wnth  rice,  barley  or  bread  crumbs  added  to  it.  Slice 
of  stale  bread;  junket  or  rice  and  milk  pudding,  (b)  Tablespoonful 
of  white  meat  of  chicken  or  rare  beef  or  mutton,  either  scraped  or 
pounded  to  a  pulp.     Slice  of  stale  bread  thinly  buttered;  junket,  rice 


310  INFANT  FEEDING 

and  milk  pudding,  or  a  boiled  custard,  (c)  Perfectly  fresh  boiled 
fish  (white  meat)  with  a  tablespoonful  of  mashed  baked  potato  moist- 
ened with  cream.     Dessert  as  in  the  preceding. 

Supper,  5  :30  or  6  p.  m.  A  bowl  of  bread  and  milk  or  a  cup  of  milk 
and  a  slice  of  bread  or  a  piece  of  zwieback.  A  cup  of  milk  may  be 
given  at  about  10  p.  m.  if  necessary. 

From  two  and  one-half  years  up  to  the  sixth  year  the  diet  of  the 
child  may  gradually  be  increased.  Milk  should  still,  however,  be 
taken  in  large  quantities — about  a  quart  daily — as  well  as  some  form 
of  cereal  for  breakfast,  with  or  without  an  egg,  or  fresh  fruit  if  there 
is  a  tendency  to  constipation.  Meat  prepared  as  above  should  be  given 
once  a  day,  and  preferably  at  the  midday  meal,  together  with  potato 
and  some  green  vegetable,  as  spinach,  asparagus,  or  cauliflower  tops. 
The  evening  meal  should  be  light,  and  consist  of  bread  and  milk. 

It  is  well  to  prepare  two  lists,  which  may  be  given  to  the  nurse  or 
mother  as  a  guide.  One  list  should  contain  the  food  allowed,  and  the 
other  list  those  forbidden.  It  is  not  well  to  depend  on  verbal  instruc- 
tions, as  they  are  easily  forgotten  or  misconstrued. 

The  Diet  from  Two  and  One-half  to  Six  Years. — Milk  may  be  al- 
lowed with  every  meal  (may  be  omitted  from  dinner  if  desired). 
The  average  child  should  take  a  quart  a  day,  plain  or,  when  plain 
milk  is  not  thoroughly  digested,  modified  as  for  twelve  to  fifteen 
months.  If  the  other  foods  are  not  taken  well  the  quantity  of  milk 
can  often  be  reduced  to  advantage. 

Cream. — Two  to  eight  ounces  a  day  mixed  with  the  milk,  taken  as 
a  beverage,  with  cereals,  etc. 

Bread  and  'biscuit  may  be  allowed  with  every  meal — stale  bread, 
dried  bread.  The  so-called  "pulled  bread,"  zwieback,  and  the  various 
forms  of  biscuits  or  crackers. 

Cereals. — Almost  any  kind  of  cereal  for  breakfast ;  oatmeal  and 
wheaten  grits  are  the  best.  Rice  and  hominy  for  dinner.  Barley  is 
useful  in  soups. 

Vegetables  may  be  allowed  for  dinner — potatoes  in  some  form  or  a 
cereal  with  one  green  vegetable:  spinach,  cauliflower  tops,  and  the 
like  are  the  best. 

Eggs  are  very  good,  but  children  are  apt  to  tire  of  them  easily. 
The}^  should  be  given  for  breakfast,  as  a  rule,  but  never  day  after 
day. 

Meat. — Allowed  once  a  day  for  dinner  and  in  older  children  for 
breakfast  occasionally.  Boiled  or  broiled  fish  may  be  given  for  break- 
fast or  dinner. 

Broths  and  soups  of  simple  composition  may  be  eaten.  Meat  broths 
with  cream  and  cereals  are  especially  nutritious. 

Desserts. — Once  a  day,  with  dinner.  Plain  custard,  milk  and  rice 
pudding,  bread  and  custard  pudding,  and  junket  are  the  best;  ice- 
cream once  a  week.     Fruit  should  be  given  once  daily,  and  only  ripe 


FEEDING  DURING  THE  SECOND  YEAR  311 

fresh  fruit,  in  season,  should  be  used.  The  best  are  oranges,  baked 
apples,  and  stewed  prunes.  Kipe  peaches,  pears,  grapes  without  skins 
or  seeds,  may  also  be  given.  Fresh  juice  of  berries  in  small  quantity, 
strawberries  in  perfect  condition  sparingly.  Ripe  cantaloupe  and 
watermelon  in  moderate  quantities  may  also  be  allowed.  Great  care 
should  be  used  in  choosing  and  giving  fruit  to  children.  It  is  a  very 
important  article  of  diet,  but  if  stale,  spoiled  or  unripe,  is  capable  of 
doing  much  harm.  Too  much  should  not  be  given  in  hot  weather. 
Lemonade  is  useful  during  very  hot  weather. 

According  to  Meals. — Breakfast — Every  day,  milk  to  drink.  A 
well-cooked  cereal,  with  salt  and  cream,  but  little  or  no  sugar.  Bread 
and  butter. 

In  addition  to  the  above,  one  of  the  following  every  day :  Eggs 
lightly  boiled,  poached,  and  for  older  children  scrambled  or  made 
into  a  plain  omelette.  Boiled  or  broiled  fish.  For  older  children  a 
very  little  finely;  chopped  beef,  mutton  chop,  or  beefsteak.  For 
younger  children  meat  at  breakfast  is  not,  as  a  rule,  necessary.  Fruit 
may  be  given  before  or  after  breakfast,  during  the  latter  part  of  the 
morning,  or  at  about  noon.  One  variety  daily,  and  if  there  is  a 
special  tendency  to  constipation,  stewed  prunes  or  baked  apples  may 
be  allowed  with  the  dinner,  but  not  on  the  days  on  which  they  have 
been  used  earlier.  Oranges,  baked  apples,  stewed  prunes,  peaches, 
pears,  grapes  without  seeds  or  skins;  ripe  apples  (the  softer  varieties 
may  be  given  -,  those  known  by  dealers  as  ' '  hard ' '  apples  are  not 
suitable  used  raw). 

Dinner. — Bread  and  butter  as  desired  every  day — not  to  be  eaten  to 
the  exclusion  of  other  foods,  however. 

Owe  soup  each  day.  Bouillon,  beef,  veal,  mutton,  chicken,  or  oyster 
broth,  which  may  be  thickened  with  barley  or  other  cereals  (either 
grain  or  flour).     Milk  and  cream  may  be  added  where  desirable. 

One  meat  daily — roasted  or  broiled.  Beefsteak,  beef,  lamb  or  mut- 
ton chop,  rare  roast  beef  or  mutton,  chicken,  white  meat  of  roast 
turkey. 

Two  vegetables  daily — one  green  vegetable  and  one  other  dish, 
usually  potato  in  some  form,  should  be  given.  Potatoes,  baked  or 
mashed,  cauliflower  tops,  asparagus-tips,  stewed  celery,  spinach, 
hominy,  plain  macaroni,  mashed  peas,  young  string-beans,  and  almost 
any  green  vegetable  in  season. 

Dessert. — Junket  is  the  best,  and  may  be  given  most  frequently,  but 
rice  and  milk  pudding,  plain  custard,  and  plain  tapioca  pudding  may 
also  be  used  in  small  quantities.  Ice-cream  once  a  week.  Fruit  in 
some  cases  may  be  used. 

Supper. — Very  light  simple  suppers  should  be  given  every  day. 
Milk,  milk-toast,  cereals,  bread  and  butter,  and,  for  older  children,  a 
little  stewed  fruit  or  baked  apple,  without  too  much  sugar. 

Articles  Forbidden  (after  Holt). — The  following  articles  should 


312  INFANT  FEEDING 

not  be  allowed  children  under  four  years  of  age,  and  with  few  excep- 
tions they  may  be  withheld  with  advantage  up  to  the  seventh  year. 

Meats. — Ham,  sausage,  pork  in  all  forms,  salted  fish,  corned  beef, 
dried  beef,  goose,  game,  kidney,  liver,  bacon,  meat-stews,  and  dressing 
from  roasted  meats. 

Vegetables. — Fried  vegetables  of  all  varieties,  cabbage,  potatoes  (ex- 
cept when  boiled  or  roasted),  raw  or  fried  onions,  raw  celery,  radishes, 
lettuce,  cucumbers,  tomatoes  (raw  or  cooked),  beets,  egg-plant,  and 
green  corn. 

Bread  and  Cake. — All  hot  bread  and  rolls ;  buckwheat  and  all  other 
griddle-cakes ;  all  sweet  cakes,  particularly  those  containing  dried 
fruits  and  those  heavily  frosted. 

Desserts. — All  nuts,  candies,  pies,  tarts,  and  pastry  of  every  descrip- 
tion ;  also  salads,  jellies,  syrups,  and  preserves. 

Drinks. — Tea,  coffee,  wine,  beer,  and  cider. 

Fruits. — All  dried,  canned,  and  preserved  fruits;  all  fruits  out  of 
season  and  stale  fruits,  particularly  in  summer. 

The  meals  should  be  given  at  fixed  hours,  which  practice  should  be 
strictly  adhered  to.  Feeding  between  meals,  even  when  consisting  of 
the  most  trifling  things,  should  be  avoided.  If  the  child  can  not  go 
from  one  meal  to  another  without  discomfort,  the  intervals  should  be 
shortened.  In  certain  cases  it  may  be  advisable  to  give  a  small  cup  of 
milk  or  broth  and  a  cracker  between  the  meals,  at  stated  intervals,  as 
in  feeding  younger  children. 

Candies,  cake,  and  the  like  should  be  kept  from  young  children. 
In  well-regulated  homes,  if  he  once  learns  that  he  can  not  have  them, 
the  child  will  soon  cease  to  demand  sweets.  The  frequent  indulgence 
in  sweets  of  various  kinds  creates  a  desire  for  them  to  the  exclusion 
of  the  other  food.  This  craving  is  analogous  to  that  for  alcohol  in 
adults.  Overindulgence  in  sweets  causes  indigestion,  headache,  and 
the  like,  ailments  that  may  easily  be  prevented. 

The  child  should  be  taught  to  eat  slowly  and  to  chew  the  food  well. 
To  this  end,  some  older  individual  should  always  be  present  at  meal- 
times to  see  that  sufficient  time  be  taken  for  the  meal,  and  that  the 
food  be  finely  divided,  as  young  children  do  not,  as  a  rule,  chew  very 
well.  The  quantity  given  to  a  healthy  child  should  depend  on  his 
appetite.  In  sick  children  this  is  not  a  reliable  guide,  and,  where 
possible,  fixed  amounts  may  be  given  (see  Feeding  of  Sick  Children). 
The  child  should  not  be  forced  to  eat,  nor  should  he  be  given  special 
articles  to  tempt  the  appetite.  If  the  food  offered  is  not  taken,  it  is 
well  to  wait  until  the  next  meal,  when  it  will  generally  be  found 
that  the  appetite  has  returned.  Loss  of  appetite  is  often  merely  an 
indication  that  the  digestive  organs  require  a  slight  rest. 

During  the  heated  portions  of  the  year  the  child  will  require  less 
solid  and  more  liquid  food.  The  same  is  true  during  sickness.  Many 
of  the  gastro-intestinal  disturbances  attributed  to  teething  are  the 
result  of  improper  feeding. 


FEEDING  DURING  THE  SECOND  YEAR 


313 


The  following  tables  taken  from  Freeman  ^  give  the  diet  after  one 
year  of  age: 

Diet  of  the  Second  Year. 


At  12  mos. 


At  15  mos. 


At  IS  mos. 


At  21  mos. 


6  A.  M. 


8-10  oz.  milk 


8  oz.  milk, 
6  oz.  gruel. 


8  oz.  milk, 
6  oz.  gruel. 


8  oz.  milk, 
6  oz.  gruel. 
Soft-boiled 

egg. 
Bread  and 

butter. 


10  A.  M. 


8-10  oz.  milk. 


8  oz.  milk. 


8  oz.  milk. 


8  oz.  milk. 


4  oz.  gruel, 
8  oz.  milk, 
14  oz.  orange-juice. 

Soft-boiled  egg, 

8  oz.  milk, 

14  oz.  orange-juice. 

4  oz.  clear  soup, 
Soft-boiled  egg, 
8oz.  milk, 
J4  oz.  orange-juice, 
Bread  and  butter. 

6  oz.  clear  soup, 
J^-1  oz.  scraped 
beef, 

i  oz.  orange-juice, 
^read  and  butter. 


Bi 


5  P.  M. 


9  P.  M. 


8-10  oz.  milk.  8-10  oz.  milk 


8oz.  milk, 
8  oz.  gruel. 


8  oz.  milk, 
6  oz.  gruel. 


8  oz.  milk, 

6  oz.  gruel. 

Bread  and 

butter. 


8  oz.  milk. 


8  oz.  milk. 


8  oz.  milk. 


Diet  of  the  TTiird  Year. 


6  A.  M. 

10  A,  M. 

1  p.  M. 

5.30  p.  M. 

Orange-juice, 
10  oz.  milk, 
6  oz.  gruel, 
Soft-boiled  egg, 
Bread  and  butter. 

8  oz.  milk. 

6  oz.  soup. 

Meat, 

Bread  and  butter. 

Vegetables, 

Dessert. 

10  oz.  milk. 
6  oz.  gruel. 
Bread  and  butter. 

Diet  after  the  Tidrd  Year. 


Breakfast. 

Dinner,  12-1  p.  m. 

Supper,  6  p.  M. 

Fruit, 

Cereal, 

Milk, 

Bread  and  butter, 

1  or  2  eggs. 

Soup, 
Meat, 
Bread  and  butter, 

Vegetables, 
Dessert. 

Cereal, 

Milk, 

Bread  and  butter. 

Diet  and  Teeth. — The  tendency  to  decayed  teeth  is  a  marked 
feature  of  modern  life.  Durand  and  others  have  found  that  infants 
fed  on  sweetened  condensed  milk  for  periods  of  more  than  five  months 
show  a  much  greater  percentage  of  decay  than  those  fed  at  the  breast 
or  on  cows'  milk  mixtures  and  he  suggests  that  where  condensed 
milk  is  used  for  any  length  of  time  that  fruit,  vegetables  and  meats 
properly  prepared  be  given  to  supplement  the  diet.  It  is  also  im- 
portant to  give  the  child  hard  foods  to  chew,  these  aid  in  erupting 
the  teeth  and  in  keeping  them  hard  and  polished.  Hard  breads, 
bones  to  gnaw  at,  bacon  rind  and  later  apples  and  salads.     At  the 

1  Archives  of  Pediatrics,  .June,  1904. 


314  INFANT  FEEDING 

end  of  the  meal  in  place  of  sticky  carbohydrates  green  salads  or  fruit 
which  have  a  tendency  to  clean  the  teeth.  Acid  fruits  have  been 
found  to  produce  a  saliva  rich  in  ptyalin  and  of  higher  alkalinity 
than  blander  foods  and  this  is  of  value  in  preventing  decay. 

DIET  OF  SCHOOL  CHILDREN 

The  period  usually  spoken  of  as  "school  days"  is  an  extremely  ac- 
tive one  physicalh\  The  vast  number  of  metabolic  changes  going  on 
and  the  growth  of  the  body  demand  a  plentiful  and  a  suitable  diet. 
Both  in  and  out  of  school  and  in  seminaries  careful  attention  should 
be  given  to  food,  fresh  air,  and  exercise.  In  other  words,  the  physical 
development  should  receive  as  much  attention  as  the  mental  growth. 
In  boarding-schools  especially  the  diet  should  be  the  subject  of  careful 
study,  the  aim  being  to  avoid  monotony  and  to  provide  a  sufficient 
and  satisfying  diet.  In  many  schools  the  dietary  is  left  to  the  discre- 
tion of  the  cook.  In  considering  school  dietaries  several  points  are 
worthy  of  consideration. 

Milk,  being  easily  digested  in  most  cases,  is  of  great  value,  especially 
for  children  whose  nutrition  is  below  normal.  It  should  be  furnished 
as  a  beverage  daily  for  breakfast  and  supper,  and  is  advisable  even 
with  dinner.  It  may  also  be  used  in  the  preparation  of  puddings  and 
soups.  Cream  is  very  valuable,  and  whenever  possible  should  be 
supplied  in  sufficient  quantities.  A  cup  of  warm  milk  with  bread  or 
crackers  is  helpful  during  the  middle  of  the  morning  and  as  a  sub- 
stitute for  tea  in  the  afternoon.  Delicate  children  and  others  may 
with  advantage  take  a  glass  of  warm  milk  a  short  time  before  going  to 
bed.  If  the  rising  hour  is  some  time  before  that  set  for  breakfast,  a 
cup  of  milk  or  of  bread  and  milk  should  be  given  on  rising. 

Eggs  may  be  used  alone  or  in  the  preparation  of  various  dishes. 
They  may  be  used  in  almost  any  way  except  fried.  Fried  eggs  are 
apt  to  be  very  indigestible.  They  are  often  prepared  in  this  way 
in  order  to  disguise  the  stale  taste  of  an  egg  that  has  been  in  storage 
for  some  time. 

Meat  is  a  very  important  part  of  the  diet,  as  it  contains  a  larger 
quantity  of  protein,  from  which  the  tissues  are  built  up,  and  in  a 
more  available  form,  than  in  any  other  form  of  food.  Milk  and  eggs 
are  also  valuable  sources  of  protein.  Meat  should  be  provided,  there- 
fore, in  sufficient  quantities,  half  pound  a  day  being,  perhaps,  a  good 
average  allowance  for  a  growing  boy,  the  larger  and  more  robust  tak- 
ing that  quantity  or  more,  the  smaller  and  more  delicate  children 
taking  somewhat  less.  Steak,  chops,  and  roasts  of  beef,  mutton,  lamb, 
fowl,  and  bacon  are  the  most  suitable  meats,  although  pork,  together 
with  meat  stews,  meat  puddings,  sausage,  and  hashes,  may  be  allowed 
in  smaller  quantities.  These  last,  while  generally  relished,  are  not 
so  digestible  nor  such  good  sources  of  nutriment  as  those  first  named. 
With  care  and  proper  preparation  many  of  their  ill  effects  can  be 
obviated.     More  meat  is  required  in  winter  than  in  summer,  and  more 


DIET  OF  SCHOOL  CHILDREN  315 

in  cold  climates  than  iu  warm.     Yeo  states  that  too  much  meat  may 
give  rise  to  ec;^ema. 

Meat  may  be  given  twice  a  day,  and  eggs  or  fresh  fish  may  be  sub- 
stituted for  it  about  three  times  a  week.  When  these  do  not  satisfy 
the  appetite,  meat  may  be  added.  For  this  purpose  cold  sliced  meat 
is  useful. 

Bread  and  butter  should  be  given  with  each  meal.  Bread  made 
from  the  whole-wheat  tlour  may  be  used  in  the  largest  quantity,  but 
it  is  well  to  supplj^  various  kinds  of  bread,  to  avoid  monotony. 
"Brown  bread"  given  continuously  becomes  very  tiresome.  Rye 
bread  may  be  given  occasionally,  and  bread  made  from  mixtures  of 
wheat  and  rye  is  very  palatable.  Rusk,  biscuit,  and  crackers  may 
also  be  supplied.  Corn-bread,  when  properly  made,  may  be  given 
once  a  M'eek  or  oftener,  and  griddle  cakes  of  buckwheat,  corn,  or  wheat 
flour  two  or  three  times  a  week.  These  last  may  be  served  with  syrup 
or  fruit-juices. 

Cereal  porridges  of  all  kinds  may  be  given  for  breakfast,  oatmeal 
being  probably  the  most  desirable. 

Vegetables  of  almost  all  varieties  may  be  used.  For  dinner  two 
varieties  should  be  given,  one  green  vegetable  and  potatoes.  Salads 
made  of  the  green  vegetables,  with  the  very  simplest  dressings,  are 
useful  additions  to  the  diet. 

Fruit  should  invariably  be  given  once  a  day. 

Sugar  should  be  provided  for  in  the  dietary.  Candies  and  many 
of  the  sweets  given  to  children  are  harmful  and  cause  indigestion  and 
dyspepsia.  If  proper  sweets  were  provided,  there  would  be  slighter 
tendency  to  indulge  in  the  less  desirable  forms  whenever  opportunity 
afforded.  With  the  meals,  and  when  the  appetite  demands  satisfying 
between  meals,  they  may  be  given  with  or  without  a  glass  of  milk. 
Regularity  should,  however,  be  observed,  and  they  should  not  be  given 
•immediately  before  or  after  a  meal.  Fruit-syrups,  sugar  syrups, 
honey,  preserved  fruits,  and  jam  may  be  eaten  with  bread.  Caramels, 
chocolate,  maple-sugar,  and  plain  sugar  taffies  are  the  best  of  the 
other  forms  of  sweets. 

Simple  desserts,  such  as  custards,  milk  puddings  with  rice,  tapioca, 
and  the  like,  bread  pudding,  plain  cakes,  and  properly  prepared  pastry 
may  be  used. 

The  beverages  should  be  water  and  milk.  Weak  cocoa  or  chocolate 
may  be  given  after  the  seventh  year.  Tea  and  coffee  should  not  be 
given  before  the  thirteenth  year,  and  may  be  withheld  advantageously 
still  longer.  Alcohol  is  not  to  be  used  except  by  a  physician's  direc- 
tion. 

Especial  care  should  be  taken  to  avoid  a  monotonous  diet,  for  there 
are  many  instances  where  the  constant  repetition  of  a  certain  form 
of  food  has  created  a  dislike  for  it  that  has  persisted  throughout  life 
or  been  overcome  only  with  difficulty. 

A  second  point  to  be  remembered  is  that  the  food  should  be  well 


316  INFA?^T  FEEDING 

prepared  and  attractively  served.  This  has  more  to  do  with  influenc- 
ing the  appetite  of  delicate,  nervous  children  than  is  generally  sup- 
posed, and  can  not  be  insisted  upon  too  strongly. 

Overeating  should  be  avoided,  and  to  this  end  an  older  person 
should  always  be  present  when  practicable;  in  school,  this  should  be 
insisted  upon.  On  the  other  hand,  a  child  should  not,  through  caprice 
or  habit,  be  allowed  to  eat  too  little.  By  exercising  a  little  tact,  most 
of  the  dislikes  which  are  not  deeplj^  rooted,  but  which  may  become  so 
if  persisted  in,  may  generally  be  overcome.  These  dislikes  are  often 
the  result  of  imitation. 

Sufficient  time  should  be  allowed  not  only  for  the  meal,  but  for  the 
performance  of  whatever  small  duties  may  be  required  of  the  child. 
A  time  should  be  set  for  one  or  two  regular  daily  visits  to  the  water- 
closet.  Hurrying  to  school  should  be  avoided.  Reading  and  studying 
immediately  before  and  after  meals  should  be  prohibited,  as  should 
bathing  or  any  very  active  exercise.  Some  light  form  of  recreation 
may,  however,  be  indulged  in.  The  hours  for  meals  should  be  so 
arranged  that  the  child  may  have  freshly  prepared  meals,  and  not  cold 
luncheons  or  warmed-over  dinners.  Lastly,  nibbling  and  eating  be- 
tween meals,  except  under  the  conditions  previously  described,  should 
be  strictly  prohibited.  In  spite  of  stringent  rules,  however,  many 
infringements  will  occur. 

It  is  by  neglect  of  the  diet,  fresh  air,  and  exercise  that  many  cases 
of  tuberculosis  gain  headway :  anemia  may  result  from  such  neglect, 
and  a  delicate,  nervous  child  be  the  outcome  of  one  that  should,  by 
right,  be  healthy. 

Very  few  actual  studies  of  the  food  requirements  of  schoolboys  have 
been  made.  Gephart  found  that  in  one  of  the  large  boys'  school  that 
the  quantity  taken  estimated  on  the  individual  meal  was  as  follows: 

Pounds.  Grams  Calories.  (p|r°ceat') 

Protein    0.1107  50.2  203  14 1 

Fat     0.1332  60.4  562  39 

Carbohydrates      0.3717  168.8  692  47 

Boys  of  from  13  to  16  calculated  on  the  basis  of  complete  rest  would 
need  from  1700  to  1800  calories.  The  boy  is  however  a  very  active 
animal  and  his  actual  food  requirements  are  about  equal  to  a  farmer 
at  hard  labor  (4000  to  4500  calories).  Half  of  the  total  food  values 
were  furnished  by  bread,  butter,  milk  and  sugar.  (See  Age  and 
Food  Requirements.)  Du  Bois  in  his  studies  of  boys  just  before 
puberty  found  that  they  had  a  heat  production  25  per  cent,  more 
than  adults  according  to  the  linear  formula  which  explains  the  great 
needs  of  boys  in  the  period  of  accelerated  growth. 

Diet  List  for  a  Boys'  School. — Breakfast,  7.30  a.  m. — Half-hour 
allowed.  Fruit.  A  cereal  with  cream.  Bread  and  butter,  eggs, 
1  Seventy  per  cent,  of  this  was  in  animal  protein. 


THE  INFANT'S  STOOLS  817 

boiled,  poached,  or  as  omelet.  Fish  occasionally.  Corn  bread  once  a 
week ;  griddle  cakes  once  a  week.     Milk  to  drink. 

Dinner,  1  v.  m. — Three-quarters  hour  allowed.  Soup ;  meat — roast- 
beef  or  mutton,  steak,  or  chicken;  fish  once  a  week;  potatoes  and  a 
green  vegetable.  Hominy  or  rice  once  a  week.  A  simple  dessert: 
fruit. 

Supper,  7  p.  m. — Half-hour  allowed.  Hash,  cold  meat,  fish,  or 
omelet  in  small  quantities.  Bread  and  butter  with  syrup  or  preserved 
fruit  or  fruit-.juice.     Plain  cake.     ]\Iilk  to  drink. 

Beginning  Cases  that  Have  Been  Previously  Improperly  Fed. — 
This  requires  judgment  and  experience.  If  the  baby  has  been  very 
much  upset,  it  is  a  good  plan  to  withhold  all  food  a  day  or  a  part  of 
a  day.  This  gives  the  digestive  organs  a  rest,  and  often  means  suc- 
cess where  failure  would  have  resulted  from  feeding  almost  any  food. 
During  the  starvation  period  plain  water  may  be  given,  or  sometimes 
a  little  weak  barley-water  or  albumin-water.  These  latter  are  useful 
when  anxious  parents  cannot  be  persuaded  the  child  will  not  starve. 
They  may  also  be  used  where  there  is  evident  hunger.  In  any  case 
the  quantity  should  be  small.  We  often  give  an  initial  purge  of 
castor  oil  in  these  cases  to  insure  getting  all  the  food  out  of  the  in- 
testine. 

A  careful  study  of  the  stools,  of  the  history  of  previous  feeding, 
and  the  symptoms  which  may  be  attributed  to  the  feeding  or  to  the 
disturbances  of  metabolism.  By  so  doing  the  diagnosis  of  the  trouble 
ma}^  be  made  and  much  valuable  time  saved  by  correct  therapy. 
A  study  of  the  following  facts  will  be  found  useful  in  this  connec- 
tion: 

The  Infant's  Stools. — A  very  fair  conception  of  the  infant's  diges- 
tion can  be  obtained  from  an  examination  of  the  stools.  This  should 
be  done  in  all  cases,  and  is  as  important  a  part  of  the  routine  as  the 
examination  of  the  heart  or  lungs. 

The  size  of  the  stool  should  be  noted  first,  although  this  is  not  of 
very  great  importance,  as  it  varies  with  the  number  of  stools  and  the 
size  and  peculiarities  of  the  child  itself. 

The  number  of  stools  is  always  to  be  considered,  but  is  not  nearly 
so  important  as  the  character  of  the  stool.  An  infant  may  have  one 
or  two  stools  a  day,  or  as  many  as  four,  five,  or  six,  but  so  long  as  the 
character  of  the  stool  remains  good,  it  may  be  regarded  as  perfectly 
normal.  In  diarrhea  the  course  of  the  disease  is  better  told  by  the 
quality  of  the  stools  than  by  the  number,  and  this  may  to  a  certain 
extent  be  said  to  be  true  of  constipation. 

The  consistence  of  the  stool  of  nursing  infants  should  normally 
be  about  that  of  butter,  although  slight  variations  either  way  are  not 
to  be  regarded  as  distinctly  abnormal.  The  stool  should  be  smooth, 
and  contain  no  curds  or  solid  masses.  In  constipation  the  stools  are 
hard  and  dry,  while  in  diarrhea  they  are  soft  or  liquid. 


318  INFANT  FEEDING 

Lumps  are  frequently  seen  in  the  stool.  These  are  usually  curds 
or  masses  of  undigested  fat.     They  may,  however,  be  clumps  of  mucus. 

Mucus  is  present  normally  in  the  stool,  and  its  presence  is  easily 
demonstrated;  it  should,  however,  be  so  intimately  mixed  with  the 
stool  that  it  can  not  be  seen  with  the  naked  eye.  Any  irritation  of 
the  intestinal  wall  causes  a  great  increase  in  the  amount  of  mucus  in 
the  stool.  In  diarrhea  and  in  intestinal  indigestion  there  may  be  large 
amounts,  and  in  constipation  considerable  mucus  may  cover  the  hard 
masses  of  feces. 

The  reaction  of  infants'  stools  is  usually  acid  or  neutral,  although 
sometimes  it  is  alkaline.  Either  acid  or  alkaline  stools  may  be  altered 
in  color.  A  return  to  a  normal  color  is  usually  brought  about  in 
these  cases  by  the  administration  of  an  alkali  when  the  stools  are  acid, 
and  vice  versa.  Alkaline  stools,  green  in  color,  may  be  produced  by 
giving  alkalis  in  large  doses  for  several  daj^s.  The  color  of  the  stool 
often  furnishes  considerable  information  as  to  the  condition  of  the 
infant.  Normally  the  color  is  a  light  butter  yellow,  but  the  stools 
may  vary  somewhat  in  this  respect,  and  be  lighter  or  darker.  In 
young  breast-fed  infants  the  stools  may  be  a  dark  yellow,  like  the  yolk 
of  an  egg.  In  artificially  fed  babies  the  stools  are  apt  to  be  very  light 
in  color  or  even  decidedly  whitish.  Rhubarb  imparts  a  yellow  color 
to  the  stool. 

White  stools  are  seen  sometimes  in  artificially  fed  children  that 
seem  to  be  otherwise  in  normal  condition.  As  a  rule,  however,  white 
stools  are  either  the  result  of  the  ingestion  of  excessive  quantities  of 
fat  or  indicate  an  absence  of  bile.  In  the  former  cases  the  stools  are 
large,  whitish,  and  have  the  characteristic  odor  of  fatty  acids,  which 
resembles  that  of  rancid  butter.  The  stool  may  be  dried  and  burnt 
with  the  same  odor  and  the  fat  may  be  dissolved  by  ether.  "When 
bile  is  absent,  the  stools  are  white  and  have  a  very  foul,  almost  cadav- 
eric, odor. 

Red  stools  may  owe  their  color  to  the  presence  of  fresh  blood  from 
the  rectum  or  the  lower  part  of  the  intestinal  tract.  When  it  comes 
from  the  upper  parts,  the  blood  is  always  black.  The  streaks  of  fresh 
blood  frequently  seen  where  hard  stools  are  passed  come  from  slight 
excoriations  of  the  anus. 

Black  stools  are  caused  by  the  presence  of  blood.  In  this  case  the 
stools  are  black  and  tarry.  The  blood  may  come  from  the  intestines 
or  stomach,  or  from  blood  swallowed,  especially  that  from  hemorrhage 
from  the  posterior  nares. 

Black  or  Mackish-hrown  stools  may  also  be  caused  by  the  adminis- 
tration of  bismuth,  iron,  or  tannic  acid.  Brown  stools  are  frequently 
seen  as  the  result  of  bacterial  and  chemic  changes  in  the  intestine  in 
the  course  of  intestinal  indigestion  and  intestinal  infection.  Raw 
beef-juice  may  give  rise  to  foul-smelling  brownish-  or  grayish-colored 
stools. 

Green  stools  are  due  to  a  large  number  of  causes.     This  may  result 


OTHER  FACTORS  IN  INFANT  FEEDING  319 

from  intestinal  indigestion  and  infection  due  to  improper  food,  usu- 
ally either  an  excess  of  sugar  or  of  fat,  or  to  the  presence  of  bacteria. 
Calomel  causes  green  stools,  and  alkalis,  if  continued  and  not  neutral- 
ized in  the  intestine,  may  produce  the  same  effect. 

Symptoms  of  Dietetic  Errors. — Too  much  stress  can  not  be  laid 
upon  the  importance  of  investigating  the  source  of  disturbances  due 
to  dietetic  errors.  There  is  ample  room  for  further  clinical  study 
of  this  subject. 

Too  Low  Protein. — The  stools  are  small  and  constipated,  if  the  other 
food  elements  are  low,  as  they  are  apt  to  be.  The  child  does  not  gain 
weight  so  rapidly  as  a  normal  child,  or  it  may  remain  stationary  or 
even  lose  weight.  It  is  anemic,  and  if  the  low  protein  is  continued, 
the  child  becomes  marantic. 

Too  High  Protein. — The  child  is  apt  to  have  colic,  vomiting  any 
time,  but  usually  half  an  hour  or  more  after  feeding.  The  stools 
contain  undigested  curds,  and  mucus,  and  may  be  yellowish  green  or 
otherwise  discolored. 

Too  Low  Sugar. — The  gain  in  weight  is  ap.t  to  be  slow,  and  the  child 
may  be  constipated.     These  infants  are  usually  thin. 

Too  High  Sugar. — Vomiting  an  hour  or  two  after  meals,  the  vomited 
matter  usually  being  sour.  Acid  eructations  are  common.  Colic  is 
frequent.  The  stools  are  generally  grass  green  and  very  irritating, 
the  buttocks  often  being  excoriated. 

Too  Low  Fat. — The  child  gains  weight  slowly,  and  is  apt  to  be 
constipated  unless  an  excess  of  sugar  is  given,  as  in  condensed-milk 
feeding. 

Too  High  Fat.^ — The  child  vomits  an  hour  or  two  after  feeding. 
Colic  is  common.  The  stools  may  be  thin  and  green  or  greenish  yel- 
low, and  contain  small  masses  of  undigested  fat  and  considerable 
mucus.  These  small  lumps  are  often  mistaken  for  curds.  They  are 
more  or  less  translucent,  and  when  burnt  give  off  the  odor  of  fatty 
acids;  they  may  be  dissolved  in  ether.  Curds  are  not,  however,  dis- 
solved in  ether.  Another  type  more  common  is  the  large,  white, 
rather  dry  stools  having  the  odor  of  rancid  butter. 

It  must  be  remembered  that  the  condition  of  the  stools  may  be  due 
to  one  or  more  of  the  food  elements,  and  experience  in  these  cases,  as 
in  most  others,  is  the  best  teacher.  It  is  only  by  practice  and  careful 
observation  that  the  feeding  of  infants  may  be  conducted  properly. 
Another  fact  to  be  remembered  is  that  the  food  need  not  be  changed  to 
meet  every  trifling  alteration  in  the  temper  of  the  child  or  in  the 
character  of  its  stools. 

OTHER  FACTORS  IN  INFANT  FEEDING 

Feeding  in  Infant  Asylums. — The  feeding  of  infants  in  over- 
crowded infant  asylums,  with  their  lack  of  fresh  air  and  paucity  of 
attendants,  is  a  matter  of  great  difficulty.  Any  attempt  at  scientific 
feeding  under  such  circumstances  will  ultimately  lead  to  failure,  the 


320  INFANT  FEEDING 

method  in  these  cases  being  held  to  blame.  The  primary  cause  of 
malnutrition  and  marasmus  in  institutions  is  the  lack  of  fresh  air  and 
individual  care,  and  until  these  are  obtainable  it  is  useless  to  attempt 
to  accomplish  anything  by  special  feeding  methods.  In  smaller  in- 
stitutions the  use  of  the  Materna  graduate  will  be  found  satisfactory. 

In  the  larger  asylums  it  is  well  to  have  two  or  three  general  working 
formulas,  such  as  fat  3  per  cent.,  sugar  6  per  cent.,  protein  1  per 
cent. ;  and  fat  4  per  cent.,  sugar  7  per  cent.,  protein  2  per  cent. 
These  may  be  varied  by  adding  more  or  less  water  to  them  to  adapt 
them  more  closelj'  to  special  needs.  The  younger  infants  may,  when 
possible,  receive  special  mixtures.  For  substitute  feeding,  condensed 
milk,  barley-  and  egg-water  will  be  found  most  useful. 

The  allowance  of  a  few  cents  a  day  generally  made  for  an  infant's 
entire  care  is  quite  inadequate  to  accomplish  any  good. 

Acute  Sugar  Poisoning. — In  cases  in  which  there  is  nutritional 
disturbance  sugar  may  at  times  cause  a  symptom-complex,  which  when 
recognized  should  be  followed  by  discontinuing  all  sugar,  and,  indeed, 
all  food  for  a  daj^  or  two.  And  when  feeding  is  begun  sugar  should 
be  withheld.  Human  milk  is  the  best  food  in  these  cases.  Albumin 
milk  or  buttermilk  is  the  best  substitute.  There  is  a  history  of  a  loss 
of  weight  and  diarrhea,  with  thin,  green  stools.  There  is  great  pros- 
tration, with  drowsiness  and  short  periods  of  coma.  There  is  irregu- 
lar, usually  high  fever,  shallow,  irregular  respiration,  weak  irregular 
pulse,  albumin  and  sugar  in  the  urine.  The  character  of  sugar  in 
the  urine  is  that  which  has  been  given.  Lactose  may  not  be  noted 
if  Fehling's  test  is  used,  as  it  requires  prolonged  boiling.  The 
phenyl-hydrazin  test  is  better. 

Finkelstein's  Classification. — An  outline  of  this  is  included,  as  it 
is  much  talked  about  at  present.  The  chief  value  of  his  work  seems 
to  us  to  be  the  use  of  albumin  milk,  the  recognition  of  food  intolerance, 
and  that  some  of  the  conditions  which  have  been  regarded  as  merely 
gastric  or  intestinal  are  more  deep  seated. 

He  separates  four  classes : 

1.  Disturbed  metabolic  balance    (Bilanz  Storung). 

2.  Dyspepsia. 

3.  Intoxication. 

4.  Decomposition  (acute  atrophy). 

1.  In  the  case  of  disturbed  metabolic  balance  the  condition  is  what 
we  describe  as  a  mild  case  of  marasmus.  There  may  be  a  congenital 
idiosyncrasy  in  regard  to  milk,  or  there  may  have  been  improper 
feeding,  especially  too  high  fat.  The  symptoms  are  either  no  gain 
in  weight  or  an  irregular  increase  below  normal,  in  spite  of  the  fact 
that  the  infant  is  getting  what  should  be  sufficient  or  even  more  than 
sufficient  food.  There  is  a  wider  range  of  temperature  than  normal, 
especially  marked  in  infants  under  six  months,  and  also  where  the 
tolerance  for  carbohydrate  is  disturbed.  The  stools  are  gray  or  white, 
dry  and  friable  if  too  much  milk  has  been  given,  and  they  are  green 


OTHER  FACTORS  IN  INFANT  FEEDING  321 

aud  tliiii  if  excessive  carbohydrate  has  been  given.  Vomiting  is  fre- 
quent and  there  is  tympanites.  The  muscles  are  soft  and  flabby  and 
the  skin  pale.  The  child  is  restless  and  irritable  and  sleeps  poorly, 
and  irritation  and  infection  of  the  skin  common. 

In  these  cases  the  protein  digestion  and  retention  are  normal.  The 
disturbance  is  due  to  fat,  carbohydrate,  or  salts  causing  an  abnormal 
reaction. 

The  treatment  of  these  cases  is  best  accomplished  by  human  milk. 
Where  this  is  not  possible,  skimmed  milk  feeding  or  buttermilk  is 
often  useful.  If  ordinary  milk  mixtures  are  used,  the  fats  may  be 
decreased  and  an  increase  made  in  the  carbohydrates.  Sometimes 
changing  the  form  of  sugar  that  is  used  is  of  value.  Malted  foods  or 
malted  milk  added  to  the  milk  may  be  of  value. 

2.  Dyspepsia. — This  represents  the  second  degree  of  severity,  and 
there  are  acute  gastric  intestinal  symptoms.  These  cases  are  due  to  a 
congenital  lowered  tolerance  to  covv^s'  milk,  to  errors  in  diet,  either  too 
much  food  or  too  much  of  some  one  element.  Feeding  vi^ith  infected 
milk  and  infectious  diseases,  either  general  or  local,  may  be  the  pri- 
mary cause. 

Finkelstein  believes  that  sugar,  salts,  and  fat  are  the  exciting  causes, 
and  advises  giving  human  milk  when  possible.  If  this  is  not  availa- 
ble, in  the  mild  cases  reduce  the  milk  and  sugar,  and  in  the  severe 
cases  reduce  sugar,  whey,  and  fats.  First,  starve  a  day  and  then  give 
buttermilk  or  one-third  boiled  milk  and  two-thirds  thin  oatmeal  gruel. 
It  is  in  these  cases  that  albumin  milk  is  especially  indicated.  (See 
above. ) 

3.  Intoxication. — These  cases  are  what  we  call  gastro-enteritis,  sum- 
mer diarrhea,  or  cholera  infantum.  They  are  due  to  food  intolerance, 
to  infected  food,  or  to  heat.  Finkelstein  believes  that  infants  in  which 
the  diet  has  been  rich  in  sugar  and  whey  will  have  an  intoxication, 
while  those  fed  on  a  diet  rich  in  fat  and  low  in  sugar  will  have 
decomposition  or  atrophy ;  that  is,  his  fourth  class  of  cases. 

The  symptoms  of  this  intoxication  class  are  what  we  call  summer 
diarrhea.  The  treatment  of  these  cases,  according  to  Finkelstein,  is  to 
starve  a  day  or  two,  but  give  sufficient  water.  Subcutaneous  salt 
solution  infusions  in  the  more  severe  cases  are  of  value,  or  salines 
per  rectum  by  the  drop  method  may  be  used.  Stimulants  and  seda- 
tives are  used  as  indicated.  Human  milk  should  be  given  if  possible, 
and  if  it  is  not,  a  diet  low  in  fat  and  sugar.  Albumin,  milk,  beginning 
with  very  small  quantities,  may  be  used.  After  the  starvation  day 
give  ten  feedings  a  day  of  5  c.c,  of  albumin  milk,  and  then  increase 
50  c.c.  a  day  until  the  stools  are  improved,  and  then  100  c.c.  a  day 
until  180  to  200  c.c.  are  given  daily  for  each  kilo  of  weight.  After 
the  stools  are  solid,  add  1  per  cent,  sugar  and  increase  gradually  to 
4  per  cent.  The  total  feeding  should  not  exceed  1000  c.c.  of  albumin 
milk  daily. 

4.  The  decomposition  or  atrophy  cases  are  characterized  by  a  lack 

21 


322  INFA^'T  FEEDING 

of  ability  to  assimilate  food.  There  is  a  subnormal,  irregular  tem- 
perature, weak  pulse,  irregular  respiration,  and  rapid  loss  of  weight. 
There  is  usually  great  hunger,  often  vomiting,  and  the  stools  are 
usually  abnormal.  Feeding  with  human  milk  is  almost  an  essential 
to  successful  treatment.  If  it  is  not  available,  buttermilk  or  albumin 
milk,  with  the  addition  of  maltose,  may  be  used. 

The  Feeding  of  Difficult  Cases. — The  feeding  of  certain  infants 
often  becomes  a  difficult  matter,  not  so  much  on  account  of  actual 
conditions  of  disease,  as  owing  to  personal  idiosyncrasy.  Others 
again  are  difficult  to  feed  because  of  actual  disease  of  the  digestive 
organs  or  on  account  of  the  lowering  of  nutrition  due  to  the  existence 
of  other  diseases.     These  cases  will  be  considered  in  proper  order. 

At  the  outset  it  must  be  remembered  that  the  fault  may  not  be  due 
to  the  food  itself,  but  to  its  preparation  or  the  mode  or  time  of  ad- 
ministration, and  to  improper  surroundings  and  care.  To  succeed  in 
these  difficult  cases  it  is  necessary  to  look  diligently  into  the  minutest 
details  of  the  infant's  life. 

Loss  of  Weight. — Loss  of  weight  in  an  infant  should  always  be 
considered  a  very  serious  symptom.  During  an  acute  illness,  such  as 
pneumonia  or  diarrhea,  this  is  to  be  expected.  In  chronic  conditions 
the  weight  may  fluctuate,  going  up  and  down,  or  remaining  more  or 
less  stationary.  If,  however,  in  a  period  of  a  month  or  two  there  is 
no  general  tendency  to  gain,  in  spite  of  the  fluctuation,  this  indication 
is  a  serious  matter.  Where  an  infant  is  losing  weight  without  any 
special  cause,  this  may  be  attributed  to  insufficient  food.  If  the  in- 
fant is  nursing,  the  breast  milk  may  be  poor  or  insufficient,  or  both. 
If  the  babe  is  bottle-fed,  the  milk  may  not  have  been  increased  in 
strength  in  proportion  to  the  child's  growth. 

It  frequently  happens  that  difficulty  is  experienced  in  obtaining  a 
food  suited  to  an  infant's  digestion.  This  end,  however,  once  attained, 
the  physician  may  increase  the  quantity,  but  not  the  quality,  of  the 
food,  and  the  infant  finally  ceases  to  increase  in  weight,  remains 
stationary,  and  then  loses.  Loss  of  weight  may  also  be  due  to  a 
food  too  rich  in  proteins  or  to  one  unsuited  to  the  infant's  digestion. 
This  latter  cause  usually,  but  not  always,  gives  rise  to  other  symptoms. 

In  all  cases  a  careful  study  of  the  food  is  essential.  Accurate 
charts  of  the  quantity  of  food  taken,  the  time,  whether  the  chile 
vomits  and  at  what  time,  and  the  number  and  character  of  the  stools, 
etc.,  are  of  great  help.  If  the  food  is  increased  or  decreased,  as  the 
case  may  be,  to  an  average  strength  for  a  child  of  the  size  and  weight 
of  the  one  under  consideration,  and  there  is  then  no  change  in  the 
child's  condition,  the  food  should  be  peptonized,  either  partially  or 
completely,  or  mixed  with  an  albuminized  or  malted  food  or  with 
barley-water.  Milk  mixtures  high  in  protein  and  carbohydrate  and 
low  in  fat  are  useful  as  are  also  malt  soup  preparations.  Condensed 
milk  with  soy  and  barley  gruel  we  have  found  of  especial  value.  Loss 
of  weight  may  be  caused  by  persistent  vomiting  (see  Vomiting). 


OTHER  FACTORS  IN  INFANT  FEEDING  323 

The  physiologic  loss  that  occurs  during  the  first  forty-eight  hours 
of  life  should  not  be  forgotten. 

Stationary  Weight. — This  frequently  follows  when  an  infant  is 
weaned  or  when  one  is  fed  artificially  from  the  outset.  Even  if  the 
child  is  receiving  correct  percentage  of  food  it  may  not  gain  for  sev- 
eral weeks.  So  long  as  the  infant  is  well  and  the  percentage  and 
(quantity  given  correspond  to  those  directed  for  an  infant  of  the  same 
age  and  weight,  no  alarm  need  be  felt,  even  if  a  month  should  elapse 
without  showing  increase  in  weight.  How^ever,  once  the  regular  gain 
in  weight  is  established,  it  should  not  remain  stationary,  but  should 
increase  gradually  from  week  to  week.  The  average  weekly  gain 
during  the  first  year  of  life  is  between  four  and  eight  ounces.  The 
weight  may  occasionally,  without  any  apparent  assignable  cause,  be  the 
same  at  one  weekly  weighing  as  it  was  at  the  preceding  one.  If  this 
persists,  a  careful  search  for  the  cause  must  be  made,  and  will  often 
be  found  to  be  insufficient  food. 

Colic. — This  is  more  apt  to  occur  in  breast-fed  than  in  bottle-fed 
babies  on  the  percentages  usually  recommended.  It  is  especially 
likely  to  come  on  during  the  first  three  months.  In  breast-fed  infants 
it  is  often  a  difficult  matter  to  overcome.  If  on  examination  the  pro- 
teins are  found  to  be  too  high,  an  effort  should  be  made  to  reduce 
them,  and  the  intervals  of  nursing  may  be  lengthened.  In  bottle-fed 
infants  colic  is  usually  due  to  the  fact  that  the  percentage  of  protein 
is  too  high.  The  condition  may  also  be  caused  by  the  food  being 
given  too  cold,  as  well  as  by  a  host  of  causes  that  bear  no  relation  to 
the  food. 

Vomiting. — Immediately  after  Feeding. —  (a)  From  the  food  being 
given  in  too  large  quantities.     Reduce  quantity. 

(6)  From  food  being  given  too  dilute,  and  so  necessitating  the 
taking  of  too  large  quantities.  Eeduce  the  quantity  and  increase  the 
strength. 

(c)  From  taking  food  too  rapidly.  Give  more  slowly — in  breast- 
fed children,  by  regulating  the  flow  by  grasping  the  nipple  between 
the  fingers;  in  bottle-fed  babies  by  using  a  nipple  with  a  smaller 
hole. 

At  any  Time. — Due  to  the  abdominal  binder  being  too  tight,  or  to 
shaking  or  holding  the  infant  with  the  head  over  the  nurse 's  shoulder, 
patting  on  the  back,  etc.  From  too  high  proteins — this  is  more  apt 
to  be  accompanied  by  other  symptoms,  as  colic,  curds  in  stools,  etc. 

One  or  Two  Hours  after  Feeding. — The  vomited  material  is  usually 
sour  and  curdled,  or  it  may  be  watery  and  contain  mucus.  This  is 
due  to  the  percentage  of  fat  or  sugar  being  too  high.  The  fat,  or 
both  fat  and  sugar,  should  be  decreased,  and  the  food  be  given  slowly 
and  at  longer  intervals. 

Vomiting  also  occurs  in  many  diseased  conditions.  It  is  a  frequent 
accompaniment  of  gastric  and  intestinal  disorders,  infection,  and  all 
acute  diseases;  it  occurs  in  nervous  diseases,  such  as  meningitis,  and 


324  INFANT  FEEDING 

in  brain  tumor,  in  peritonitis,  and  in  intestinal  obstruction,  with 
coughing  spells,  as  a  habit,  or  retlexly  from  intestinal  or  pharyngeal 
irritation,  or  in  toxic  conditions,  such  as  uremia.  The  treatment  de- 
pends on  removal  of  the  cause  where  possible.  When  it  occurs  in 
ordinary  acute  diseases,  however,  much  can  be  done  in  a  general  way 
to  overcome  vomiting.  The  food  should  be  given  in  sufficiently  small 
quantities  at  two-hour  intervals,  or  in  some  cases  a  teaspoonful  of 
food  may  be  given  every  hour,  or  even  every  half -hour  where  larger 
quantities  are  not  retained.  If  the  ease  is  acute,  it  may  be  necessary 
to  secure  a  wet-nurse  (see  Inanition).  Washing  out  the  stomach  and 
gavage  are  two  very  important  means  of  treating  persistent  vomiting 
which  should  not  be  forgotten. 

GAVAGE 

Gavage,  or  feeding  by  means  of  a  stomach-tube,  is  a  method  used 
in  various  diseases  and  conditions  of  infancy  and  childhood.  In  cases 
where  the  child  is  not  able  to  take  nourishment,  or  only  in  insufficient 
amount,  and  in  cases  of  uncontrollable  vomiting,  this  method  may  be 
resorted  to.  It  is  used  in  the  feeding  of  premature  infants,  whether 
in  an  incubator  or  not,  and  in  cases  of  small,  weak,  marantic  infants 
who,  owing  to  weakness  or  lack  of  appetite,  do  not  take  sufficient 
nourishment.  It  is  also  employed  after  surgical  operations  about 
the  head  or  neck  where  swallowing  is  interfered  with,  and  in  acute 
diseases,  such  as  pneumonia,  in  fevers,  and  in  delirium  or  coma. 

The  results  that  follow  this  method  of  feeding  are  surprising,  es- 
pecially in  cases  where  there  is  constant  vomiting  or  where  the  stom- 
ach has  a  very  small  capacity.  In  the  former  case  the  vomiting  may 
cease  and  the  food  be  retained ;  in  the  latter,  the  capacity  of  a  stomach 
that  previously  held  only  an  ounce  or  two  may  rapidly  be  increased 
until  an  average-sized  feeding  is  retained  with  ease. 

The  technic  of  the  method  is  simple,  and  the  procedure  conducted 
without  difficulty  in  children  under  one  year  of  a^e;  above  that 
age  it  may  be  difficult,  and  a  mouth-gag  may  be  required;  in  some 
cases  nasal  feeding  must  be  substituted.  The  apparatus  employed  is 
the  same  that  is  used  for  washing  out  the  stomach,  and  since  it  is 
frequently  desirable  to  wash  out  the  stomach  before  introducing  the 
meal,  the  same  tubing  may  serve  for  both  purposes.  It  consists  of 
a  soft-rubber  catheter  connected,  by  means  of  a  piece  of  glass  tubing, 
to  a  piece  of  rubber  tubing  to  the  other  end  of  which  a  funnel  is 
attached.  The  nurse  holds  the  child  on  her  lap,  with  the  head  held 
straight  and  not  inclined  in  either  direction.  The  catheter  is  moist- 
ened with  warm  water  and  held  several  inches  from  the  end,  so  as 
to  allow  enough  of  it  to  pass  into  the  esophagus  with  the  first  attempt 
at  introduction.  The  mouth  is  opened,  if  necessary,  and  the  catheter 
passed  rapidly  into  the  pharynx-,  there  is  usually  a  swallowing  move- 
ment, and  the  tube  is  readily  passed  into  the  stomach.  If  the  pro 
cedure  is  carried  on  too  slowly,  the  tongue  may  interfere,  or  if  the 


DIET  ly  DISEASES  OF  CHILDREN  325 

catheter  is  held  too  near  the  end,  it  may  cause  gagging.  Before 
introducing  the  food  it  is  well  to  wash  out  the  stomach  with  normal 
salt  solution.  As  soon  as  all  the  food  has  entered  the  stomach,  the 
catheter  is  pinched  and  rapidly  withdrawn.  If  it  is  withdrawn 
slowly,  the  food  ma}'  come  up  with  the  tube.  If  the  catheter  is  left 
open  as  it  is  withdrawn,  the  dripping  into  the  pharynx  may  cause 
vomiting.  If  the  child  is  young,  it  is  a  good  plan  to  keep  the  finger 
between  the  jaws  for  a  few  moments  to  prevent  gagging.  If  the  food 
comes  up,  the  feeding  must  be  repeated. 

Nasal  Feeding. — For  this  purpose  a  catheter  in  proportion  to  the 
size  of  the  child  should  be  used,  ,  The  procedure  is  the  same  as  that 
for  adults.     (See  Forced  Feeding.) 

DIET  IN  DISEASES  OF  CHILDREN 

Cyclic  Vomiting. — This  is  a  curious  derangement  of  metabolism, 
in  which  there  is  an  acidosis  that  may  have  been  started  in  one  or 
several  ways.  In  addition  to  the  acid  poisoning,  there  is  said  to  be 
a  disturbance  in  the  ratio  of  the  excretion  of  uric  acid  to  urea.  Dur- 
ing the  attack  it  is  well  to  give  the  stomach  absolute  rest,  as  food  and 
drink  tend  to  aggravate  the  condition.  Sodium  bicarbonate  solutions 
should  be  administered  by  rectum  by  the  ]\Iurphy  drop  method,  and 
they  may  be  alternated  with  glucose  solutions,  5  per  cent,  being  a 
desirable  strength.  The  soda  is  useful  in  combating  the  acidosis,  and 
the  glucose  furnishes  a  carbohydrate  which  is  extremely  useful  in 
establishing  a  normal  metabolism  in  the  acid  conditions.  If  the  at- 
tack is  prolonged,  additional  rectal  feeding  may  be  given.  Small 
doses  of  atropin  administered  by  stomach  is  sometimes  useful.  When 
the  vomiting  stops,  it  is  best  to  have  rest  for  some  hours  before  the 
feeding  is  resumed.  For  the  first  day  of  mouth  feeding,  milk  to 
which  lime-water  has  been  added,  or  skimmed  milk  with  8  grains  of 
citrate  of  soda  added  to  each  ounce,  peptonized  milk,  albumin-water, 
or  barley-water  may  be  used.  After  three  or  four  days  a  return  is 
made  to  the  ordinary  diet.  As  a  rule,  when  the  attack  is  over,  con- 
valescence is  rapid.     (See  also  Acidosis). 

The  diet  in  the  interval  is  important  and  requires  considerable 
study  to  adapt  it  to  the  particular  child,  but  much  can  be  done  to 
lengthen  the  interval  between  the  attacks.  It  is  also  important  to 
have  the  child  out  of  doors  as  much  as  possible,  as  much  exercise  as 
can  be  given,  but  carefully  avoiding  fatigue.  All  sorts  of  nervous 
excitement  must  be  avoided.  The  diet  should  be  so  planned  as  to 
allow  an  excess  of  alkalis  (See  Alkalis  and  Acids),  and  this  is  usually 
easily  done.  Lean  meats,  eggs,  milk,  potatoes,  green  vegetables  and 
fruits  generally  must  furnish  the  bulk  of  the  diet,  but  cereals  and 
bread  stuffs  should  be  allowed  in  moderation.  The  fats  should,  as 
a  rule,  be  low. 

Some  cases  seem  to  show  a  close  relation  to  the  carbohydrate  intake 
and  in  starvation  or  in  the  absence  of  carbohydrates,  attacks  may  be 


326  INFAXT  FEEDING 

precipitated  or  if  the  carbohydrate  is  insufficient  in  amount  the  at- 
tacks may  be  more  frequent.  In  some  cases  the  fats  are  in  excess 
or  the  balance  between  the  fats  and  carbohydrates  is  at  fault  and  can 
be  helped  by  lowering  the  fat  intake.  In  some  cases  the  overuse  of 
sugar  seems  to  be  the  fault  and  the  acidosis  may  be  connected  with 
abnormal  chemical  changes  in  the  bowel.  Cutting  out  the  sugar  (not 
all  the  carbohydrates )  will  be  of  great  service.  "VVe  are  of  the  opinion, 
after  a  considerable  experience,  that  the  interval  between  the  attacks 
can  be  lengthened  if  the  case  is  thoroughly  studied  and  the  co- 
operation of  the  famil}'  secured. 

A  saline  purge  at  intervals  of  from  one  week  to  a  month  seems  to 
be  of  value  and  the  administration  of  sodium  bicarbonate  from  time 
to  time  should  be  tried.  Celestius  vichy  is  a  pleasant  way  of  furnish- 
ing additional  alkalis. 

Stomatitis. — In  stomatitis  the  feeding  often  becomes  a  matter  of 
great  importance.  In  the  milder  forms  there  is  not  much  difficulty 
in  getting  the  child  to  take  liquid  nourishment,  especially  if  it  is  given 
cold.  In  the  severer  forms,  such  as  ulcerative  stomatitis,  the  child 
may  refuse  all  food.  In  these  cases  it  should  be  offered  food  in  the 
form  of  ice-cold  milk,  albumin-water,  and  the  like.  If  all  food  is 
refused,  or  if  insufficient  quantities  are  taken,  rectal  feeding  must 
be  instituted.  In  some  cases  nasal  feeding  may  be  resorted  to,  but  in 
many  patients  where  this  is  indicated  it  can  not  be  employed  because 
of  the  inflammation  extending  into  the  nares.  In  all  cases  the  diet 
should  be  similar  to  that  used  in  scurvy.  Fresh  fruit-juices  and 
vegetables  are  to  be  given.  In  the  ulcerative  cases  chlorate  of  potas- 
sium or  mineral  acids  are  useful. 

Acute  Gastric  Indigestion — Acute  Gastritis. — As  these  diseases 
can  not,  as  a  rule,  be  distinguished  from  each  other  at  the  outset,  and 
since  the  dietetic  indications  are  along  similar  lines,  they  may,  for 
convenience,  be  considered  together. 

The  main  indications  are  to  empty  the  stomach  and  to  give  it  rest. 
If  possible,  it  should  be  cleansed  by  washing  with  a  tube  and  an 
abundance  of  warm  water ;  where  this  is  not  possible,  warm  water  may 
be  given  to  drink,  and,  if  necessary,  vomiting  induced. 

Food  should  be  discontinued  entirely  for  six  hours,  and  during 
this  interval  small  quantities  of  hot  water  may  be  given.  At  the  end 
of  this  time,  if  the  vomiting  has  ceased,  small  amounts — 1  to  3  ounces 
■ — of  barley-water  may  be  administered.  ]\Iilk  in  any  form  should  be 
withheld  for  twenty-four  hours,  when,  if  the  baby  is  breast-fed,  it 
may  be  nursed  for  a  few  minutes  at  three-hour  intervals.  If  this  is 
found  to  agree  with  the  child,  the  time  of  nursing  may  be  leng-thened 
and  the  intervals  between  feedings  shortened.  If  the  baby  is  bottle- 
fed,  it  is  well  to  withhold  cows'  milk,  and  to  give  barley-water  or 
rice-water  in  its  stead:  when  the  stomach  has  become  tolerant,  other 
articles  may  be  added.  At  first  broths,  free  from  fat,  and  meat-juice 
may  be  tried,  followed  by  malted  milk.     Only  small  quantities  should 


DIET  IN  DISEAiiEU  OF  CHILDREN  327 

be  given  at  first,  and  at  intervals  of  three  or  four  hours.  As  improve- 
ment occurs  the  food  may  be  given  oftener  and  in  increasing  quan- 
tities. In  the  severe  cases,  where  vomiting  persists,  prepared  foods, 
such  as  Panopepton  or  Liquid  Beef  Peptonoids,  diluted  with  water, 
may  be  retained.  For  the  younger  infants  and  for  older  infants  if 
the  stomach  is  at  all  irritable,  it  is  well  to  peptonize  the  cows'  milk 
when  it  is  first  given.  For  older  infants  a  small  amount  of  milk 
may  be  added  to  a  large  quantity  of  a  cereal  water,  such  as  barley- 
water.  It  may  be  well  to  boil  the  two  together  for  a  few  minutes. 
The  amount  of  milk  may  gradually  be  increased,  an  equal  volume  of 
lime-water  being  added  to  it  at  first.  If  the  stomach  is  very  irritable, 
small  doses  of  hot  w^ater  frequently  repeated  may  be  tried,  or,  what 
is  usually  of  greater  service,  teaspoonful  doses  of  equal  parts  of  lime- 
water  and  cinnamon-water. 

Chronic  Gastric  Indigestion — Clironic  Gastritis. — While  different 
pathologic  conditions  are  present  in  these  diseases,  the  treatment  is 
practically  the  same,  and  for  this  reason  they  may  be  considered  to- 
gether. In  both  diseases  the  food  is  apt  to  be  retained  in  the  stomach 
for  a  long  time ;  it  is  also  likely  to  be  imperfectly  digested,  the  large 
amount  of  mucus  which  is  usually  present  in  itself  interfering  with 
digestion.  The  stomach  should  be  washed  out  once  or  several  times 
a  day  with  warm  water  or  with  a  weak  solution  of  sodium  bicarbonate 
(1  dram  to  the  pint).  The  food  should  be  given  at  intervals  of  three, 
four,  or  even  five  hours,  according  to  the  age  of  the  child.  It  should 
be  suited  to  the  infant's  digestion,  and  what  has  been  said  about 
infant  feeding  in  general  and  the  feeding  of  difficult  cases  applies 
here.  Patience  and  judgment  are  necessary  to  determine  what  is  the 
best  food  for  the  infant  and  just  how  long  it  should  be  continued 
without  a  change.  In  this,  as  in  so  many  other  conditions,  experience 
is  the  safest  guide.  The  milk  may  be  partially  peptonized  or  a  milk 
low  in  proteins  may  be  given.  A  milk  low  in  fats  is  often  attended 
by  good  results.  Occasionally  the  sugar  may  be  reduced  with  ad- 
vantage, or  condensed  milk  or  one  of  the  proprietary  foods  may  be 
tried.  Barley-water  and  milk  in  varying  proportions,  but  usually 
with  a  large  amount  of  barley-water,  may  be  digested.  Barley-water 
and  a  weak,  fat-free  veal  broth  may  be  mixed  together  in  equal  quan- 
tities and  used  to  advantage.  In  some  cases  whey  mixed  with  barley- 
or  rice-water  may  be  tried,  and  if  it  is  possible  to  give  fat  without 
causing  vomiting,  cream  in  small  amounts  may  be  added  to  the  mix- 
ture. 

General  hygienic  measures  should  carefully  be  observed. 

Dilatation  of  the  Stomach. — The  methods  of  diagnosis  and  treat- 
ment of  this  condition  are  similar  to  those  when  the  disease  occurs  in 
adults.  The  essentials  of  the  treatment  are  stomach-washing,  small 
meals  at  sufficiently  long  intervals,  and  tonics,  such  as  strychnin  and 
nux  vomica.  The  character  of  the  food  should  be  about  the  same  as 
that  advised  for  chronic  gastritis. 


328  INFANT  FEEDING 

Pylorospasm  and  Hypertrophy  of  the  Pylorus. — In  hypertrophy 
the  Rammstedt  operation  of  cutting  the  pyloric  muscle  should  be  done 
as  soon  as  the  diagnosis  is  certain.  After  the  operation  the  diet  as 
outlined  by  Morgan  is  as  follows: 

"The  patient  is  given,  an  hour  after  operation,  provided  the  re- 
covery from  the  anesthetic  has  been  complete,  16  c.c.  of  water,  and 
an  hour  later  12  c.c.  of  breast  milk  mixed  with  4  c.c.  of  water.  It 
may  be  necessary-  at  first  to  use  a  medicine  dropper  for  the  administra- 
tion. The  breast  milk  is  repeated  ever}'  three  hours,  eight  feedings 
a  day,  and  is  alternated  with  water.  Both  are  gradually  increased 
so  that  twenty-four  hours  after  operation  16  to  24  c.c.  of  undiluted 
breast  milk  is  being  given  every  three  hours  and  a  similar  amount 
of  water  between  feedings.  At  the  end  of  forty-eight  hours  the  child 
is  usually  taking  20  to  30  c.c,  at  the  end  of  seventy-two  hours  30 
to  45  c.c.  at  a  feeding.  The  administration  of  water  by  mouth  during 
the  first  three  or  four  days  is  of  the  greatest  importance.  The  time 
required  to  increase  the  milk  to  meet  the  caloric  requirements  of  the 
child  has  been  on  an  average  five  days ;  in  small  babies  three  days  may 
be  sufficient,  and  in  the  well  nourished  as  much  as  eight  to  ten  days. ' ' 

In  doubtful  cases  the  stomach  should  be  washed  out  and  all  food  given 
bj^  means  of  a  stomach-tube  until  the  vomiting  ceases  to  recur.  If  the 
vomiting  is  verj'  persistent,  rectal  feeding  may  be  tried.  Glucose  solu- 
tion is,  perhaps  the  best  remedy  to  be  used,  and  the  drop  method 
should  always  be  tried  by  preference.  Small  doses  of  atropin  sulphate 
(y2ooo  grain  for  young  infants)  may  be  administered  from  four  to 
six  hours,  often  with  very  marked  effects.  ]Mothers'  milk  (which  at 
first  has  the  cream  removed)  is  the  best  food,  but  mixtures  of 
skimmed  milk  and  water  to  which  3  grains  of  sodium  citrate  has  been 
added  to  each  ounce  may  be  used.  Peptonized  milk  is  also  useful. 
Meat  juices  have  been  suggested,  but  milk  feeding  is  probably  better. 

Diarrhea  in  Infants. — It  should  be  remembered  that  diarrhea  may 
be  present  in  a  great  variety  of  different  conditions,  and  there  are 
many  complicating  theories  concerning  it,  and  also  concerning  the 
dietetic  treatment. 

Some  cases  are  simple,  and  are  due  to  drugs,  to  laxative  fruits,  or 
to  gross  errors  in  diet.  Other  cases  seem  to  be  caused  by  thermic 
influences,  heat  or  cold,  but  usually  extreme  heat.  Some  cases  are 
reflex,  or  are  due  to  general  or  local  diseases  not  directly  connected 
with  the  digestive  tract.  Some  are  due  to  impure  milk,  and  are 
either  caused  by  bacteria  or  toxins  (ptomains)  which  have  been 
formed  in  the  milk.  In  some  the  dysentery  bacillus  is  the  cause,  the 
disease  being  simply  a  dysenterj^  in  an  infant.  At  other  times 
streptococcus  infections  of  the  intestine  or  other  definitely  pathogenic 
bacteria  may  be  the  cause.  Sometimes  protozoa  or  other  forms  of 
animal  parasites  may  cause  the  trouble.  There  is  local  disease  and 
constitutional  disturbance,  which  varies  greatly  both  in  its  extent, 
manifestations,  and  dangers.     Some  cases  are  due  to  food  intolerance. 


DIET  IN  DISEASES  OF  CHILDREN  329 

These  are  usually  due  to  feeding  too  much  fat  or  too  much  sugar, 
or  to  the  child's  having  a  lowered  resistance  for  one  or  the  other. 
Sometimes  the  metabolism  of  the  salts  may  be  at  fault.  (See  Finkel- 
stein's  classification.) 

We  try  to  classify  the  cases  clinically  as  regards  feeding  into  (1) 
simple  diarrheas  where  there  are  no  serious  local  or  general  dis- 
turbances, although  some  of  these  cases  may  present  alarming  symp- 
toms; (2)  intestinal  intoxications  and  infections  in  which  there  is 
the  added  element  of  either  a  toxin  or  of  pathologic  bacteria;  and 
(3)  cases  in  which  there  is  more  or  less  disturbance  due  to  food  in- 
tolerance and  where  there  may  be  a  marked  derangement  in  metabol- 
ism. 

It  is  well  to  remember  that  the  diagnosis  of  these  present  unusual 
difficulties  at  times.  One  cannot,  as  a  rule,  tell  whether  the  diarrhea 
is  simple,  infectious,  or  a  food  intolerance,  although  with  experience 
one  may  at  times  make  the  diagnosis  at  the  start.  A  diarrhea  in  a 
child  fed  on  the  breast  alone  is  generally  simple.  A  diarrhea  in  a 
bottle-fed  child  when  the  mean  temperature  is  around  80°  F.  and  the 
humidity  high  is  usually  an  intoxication  or  an  infection.  The  cases 
due  to  food  intolerance  have  the  history  of  stationary  weight  with 
or  without  some  digestive  disturbance,  or  there  have  been  symptoms 
referable  to  overfeeding  of  fat  or  sugar  or  of  an  intolerance  for  one 
or  the  other.  Feeding  with  too  high  fat  and  too  high  sugar  at  the 
same  time  is  more  liable  to  cause  the  trouble  than  when  one  element 
alone  is  too  high.  There  is  usually  no  especial  intolerance  to  protein 
unless  the  normal  limit  has  been  considerably  exceeded. 

The  Diet  in  Simple  Acute  Diarrheas. — In  the  breast-fed  baby  an 
initial  purge,  preferably  of  castor  oil,  and  plain  water  until  the  bowel 
has  been  emptied,  is  usually  all  that  is  required.  If  there  is  vomiting, 
the  breast  may  be  withheld  until  the  stomach  is  quiet.  Washing  out 
the  stomach  in  these  cases  usually  stops  the  vomiting.  A  little  water 
before  feedings,  to  dilute  the  milk  in  the  stomach  and  to  somewhat 
lessen  the  amount  taken,  is  usually  all  that  is  required. 

In  the  bottle  fed  and  the  partly  bottle  fed  one  cannot  tell  at  the 
onset  what  the  nature  of  the  disease  is  going  to  be.  It  is,  therefore, 
important  to  have  the  diet  meet  any  emergency.  Stop  all  food  of 
whatever  kind  and  give  a  dose  of  castor  oil  or,  if  that  is  vomited,  of 
calomel.  A  tenth  of  a  grain  every  twenty  minutes  for  ten  doses  is 
usually  effective.  Smaller  doses  may  be  used  in  young  infants.  Sal- 
ines may  be  used  if  preferred.  We  greatly  prefer  castor  oil  if  it  can 
be  retained.  For  twenty-four  hours  nothing  except  plain  water 
should  be  given  or,  at  most,  a  little  thin  barley-water  or  a  little  weak 
albumin-water.  In  the  partly  breast-fed  babies  who  are  manifestly 
not  ill,  a  little  breast  milk  may  be  allowed  if  there  is  no  vomiting. 
If  there  is  any  doubt,  starve  the  child  for  the  first  twenty-four  hours. 
At  this  point  we  wish  to  remind  our  readers  that  we  refer  to  acute 
diarrheas  in  children  whose  stools  have  been  normal.     We  have  seen 


330  INFAXT  FEEDING 

babies  suffering  from  mild,  chronic,  intestinal  indigestion  given  the 
most  heroic  treatment,  which  they  did  not  need.  After  twenty-four 
hours,  if  the  vomiting  continues,  the  stomach  should  be  washed  out, 
either  with  plain  water  or,  better,  a  weak  (1  dram  to  the  pint)  sodium 
bicarbonate  solution.  If  there  are  toxic  symptoms  from  the  outset, 
it  is  well  to  wash  out  the  bowel  as  well. 

After  twenty-four  hours  the  diet  will  have  to  be  decided  upon 
according  to  the  condition  of  the  child.  There  are  no  fixed  rules, 
and,  unless  care  is  taken  to  consider  each  case  on  its  own  merits,  there 
will  be  more  failures  than  successes.  If  the  child  is  free  from  fever, 
and  is  looking  and  feeling  well,  it  does  not  always  mean  that  the 
child  is  out  of  danger,  although  these  are  very  favorable  signs.  In 
these  cases  we  allow  a  thin  barley-gruel,  rice-gruel,  or  albumin-water. 
These  may  be  given  in  from  half  to  the  full  size  of  the  customary 
feeding,  according  to  circumstances.  In  strong  children  the  full 
amounts  may  generally  be  allowed.  In  this  class  of  cases,  at  the  end 
of  another  twenty-four  hours,  the  feeding  may  be  increased  and  the 
gruels  may  be  made  thicker.  In  some  cases  we  add  a  teaspoonful  of 
condensed  milk  to  one  of  the  feedings,  and,  if  well  borne,  this  may  be 
increased  to  something  under  what  might  be  given  a  normal  child  of 
the  same  age  and  weight.  Sometimes  we  use  malted  milk  in  the  same 
way.  At  other  times  a  soy  bean  gruel  will  be  found  satisfactory.  In 
this  class  of  cases  we  generally  give  bismuth  subcarbonate  or  subnitrate 
in  10-grain  doses  in  a  dram  of  chalk  mixture.  This  may  be  ad- 
ministered every  two  hours.  If  the  stools  are  not  normal,  but  show 
evidence  of  fermentation,  buttermilk  diluted  to  about  the  usual  dilu- 
tion of  cows'  milk  may  be  given.  Plain  water  or  barley-gruel  may  be 
used  as  a  diluent.  If  buttermilk  cannot  be  obtained,  a  skimmed  milk 
soured  by  the  lactic  acid  bacillus  tablets  (of  which  there  are  a  number 
of  different  brands  on  the  market)  may  be  used.  The  souring  should 
be  complete  before  the  milk  is  ready  for  use.  There  is  usually  no 
objection  to  adding  a  little  sugar.  Sometimes  it  is  an  advantage.  In 
the  severer  class  of  cases  the  sugar  is  best  omitted.  Most  infants  do 
not  like  buttermilk  the  first  time  they  taste  it,  but  it  is  the  excep- 
tional infant  who  will  not  eventually  take  it  readily.  Under  its  use 
the  stools  often  become  smooth  and  yellow,  and  the  child  makes  a 
rapid  return  to  normal.  The  buttermilk  feeding  is  continued  for  a 
short  time  if  desired,  and  even  for  a  long  period  if  the  child  continues 
to  gain.  Lactic  acid  bacillus  tablets,  especiallj^  the  Bulgara  tablets, 
have  been  found  of  value  in  the  infectious  forms  of  diarrhea.  Gen- 
erally, after  a  week  or  ten  days  of  normal  stools  the  diet  may  be 
changed  to  the  customary  food.  It  is  sometimes  an  advantage  in 
making  the  change  to  starve  the  child  for  a  short  period  of  from 
twelve  to  twenty-four  hours,  and  then  begin  very  gradually,  as  in 
beginning  bottle  feeding.  In  the  severer  class  of  cases  albumin-milk 
may  be  used,  beginning  immediately  after  the  period  of  starvation, 
and  following  the  directions  for  its  use.     Albumin-milk  is  a  valuable 


DIET  ly  DISEASES  OF  CHILDREN  331 

addition,  but  it  must  be  properly  used  to  obtain  good  results.  Direc- 
tions are  given  under  the  heading  of  Albumin-milk. 

In  the  severe  classes  of  cases,  with  a  great  deal  of  vomiting,  large 
and  frequent  stools,  and  great  prostration,  the  feeding  is  often  a 
grave  problem.  It  frequently  happens  that  nothing  is  retained  b}^  the 
stomach,  and  it  is  not  possible  to  use  the  Murphy  drop  method  to  give 
water  or  salt  solution.  Sodium  bicarbonate  may  also  be  used  (see 
Acidosis).  In  these  cases,  if  there  has  been  much  loss  of  fluid  from 
the  body,  normal  salt  solution  may  be  given  subcutaneously.  Eight 
ounces  (250  c.c.)  may  be  used  at  one  time,  but  given  in  several  differ- 
ent places  under  the  skin  of  the  abdomen  or  buttocks  or  back.  This 
may  be  repeated  twice  daily  if  necessary.  Later,  plain  water  may  be 
given  by  mouth.  If  that  is  retained,  small  amounts  of  brandy  or  old 
whisky  diluted  with  water  may  be  given,  and  subsequently  albumin- 
water  started  in  teaspoonful  doses.  Sometimes  washing  out  the 
stomach  and  then  feeding  by  means  of  a  tube  will  be  found  useful. 
When  food  begins  to  be  retained,  several  ditferent  things  may  be  used. 
Albumin-milk  used  according  to  directions  is  sometimes  well  borne. 
Very  dilute  buttermilk  is  also  of  great  service.  Sugar  and  cereal 
gruels  are  to  be  added  to  these  after  they  have  been  given  several  days 
to  increase  the  food  value.  Cereal  gruels  and  weak  broths,  to  which 
cereal  gruels  have  been  added,  may  be  of  use.  ^Yhere  the  sugar 
metabolism  is  not  too  much  disturbed,  condensed  milk  or  malted  milk 
may  be  added  to  the  cereal  gruels  after  several  days.  To  begin  with, 
one  teaspoonful  of  either  2  ounces  or  even  less  should  be  given,  and 
if  there  are  no  untoward  effects  the  amount  may  be  cautiously  in- 
creased to  the  normal  strength  or  slightly  below  it.  The  soy  bean 
flour-gruel  may  be  used  to  great  advantage  in  these  cases,  beginning 
with  small  quantities  and  increasing,  as  suggested  in  the  directions 
for  using  the  bean.  Women's  milk  is  of  great  service  in  these  cases 
after  the  acute  stage  is  over,  and  there  is  a  period  of  undernutrition 
which  is  difficult  to  overcome.  A  wet  nurse  may  be  used,  or  the  milk 
may  be  obtained  by  using  a  breast-pump.  Milk  may  usually  be  pro- 
cured in  this  manner  when  a  wet-nurse  cannot  be  secured.  Partial 
feeding  with  women's  milk  may  be  used,  as  it  is  often  not  possible 
to  obtain  the  full  amount. 

Beef -.juice  and  the  proprietary  solutions  containing  beef  and  alcohol 
are  sometimes  useful,  but  in  the  amounts  in  which  they  are  usually 
administered  really  add  but  little  to  the  needed  amount  of  food,  and 
one  is  apt  to  be  misled  as  to  their  food  value.  Beef-juice  is  liable  to 
cause  loose  foul-smelling  stools. 

The  severe  cases  of  diarrhea  dependent  on  or  associated  with  food 
intolerance  are  usually  difficult  to  deal  with  from  the  dietetic  stand- 
point. The  mild  forms,  in  which  the  general  health  of  the  child  is 
not  much  affected,  generally  yield  promptly  on  reducing  the  excessive 
fat  or  sugar,  as  the  case  may  be.  The  cases  which  present  severe 
symptoms  of  intoxication  may  prove  rapidly  fatal,  and  these  patients 


332  /AF^AT  FEEDING 

may  reject  food  of  any  kind.  In  the  sugar  cases,  the  symptoms  of 
which  are  noted  below,  a  day  of  starvation,  with  plenty  of  water  by 
mouth  or  rectum,  or  salt  solution  subcutaneously,  if  needed,  is  in- 
dicated. This  may  be  followed  by  a  diet  of  albumin-milk  or  of  diluted 
buttermilk,  and  the  results  are  often  quite  satisfactory.  As  soon  as 
the  stools  become  yellow,  boiled  cereal  gruels  may  be  added  to  the 
food,  and  low  percentages  of  sugar  may  be  used  with  caution.  Later, 
the  sugar  percentage  in  the  food  may  be  kept  rather  low.  The  toler- 
ance for  sugar  often  returns  if  the  child  is  properly  dieted.  The 
cases  due  to  fat  intolerance,  also  noted  below,  generally  yield  to  a 
diet  low  in  fat,  albumin-milk,  or  buttermilk.  The  subject  of  food  in- 
tolerance in  infants  needs  further  study  and  clinical  observation. 

Diarrhea  in  Older  Children. — When  diarrhea  occurs  in  older  chil- 
dren, the  early  dietetic  treatment  is  similar  to  that  recommended  for 
infants.  As  the  child  recovers  a  return  to  the  ordinarj^  diet  may  be 
made,  meat,  eggs,  and  broths  of  various  kinds  being  given  at  first, 
followed  by  boiled  milk  and  toast  or  dry  bread.  Vegetables  and 
fruits  should  be  given  only  after  recovery  is  complete,  and  their  effect 
should  carefully  be  watched.  Cereals  may  also  cause  a  recurrence  of 
the  trouble,  and  should  be  most  thoroughly  cooked  and  given  in  small 
quantities  at  first. 

Ileocolitis. — This  term  is  used  to  include  those  bowel  conditions 
in  which  there  are  serious  lesions  in  the  intestine.  The  disease  usu- 
ally follows  a  summer  diarrhea.  The  dividing-line  between  the  two 
is  hard  to  draw,  and  it  is  very  probable  that  ilecolitis  is  merely  a 
severe  form  of  infection  with  the  Shiga-Flexner  bacillus  or  other 
bacteria.  The  term  dysentery  is  also  frequently  applied  to  this  af- 
fection. Conditions  resembling  this  disease  may  come  on  in  the 
course  of  chronic  disorders. 

The  feeding  of  these  cases  is  a  difficult  problem.  In  general  the 
diet  is  similar  to  that  given  in  diarrhea.  As  all  nourishment  is  usu- 
ally refused,  however,  when  the  disease  is  protracted,  as  it  is  apt 
to  be,  it  is  extremely  difficult  to  sustain  the  child,  and  the  skill  and 
tact  of  both  nurse  and  physician  are  tested  to  the  utmost. 

In  the  acute  cases,  when  there  is  vomiting,  it  is  a  good  plan  to 
withhold  all  food  for  the  first  day  or  two.  Water  may  be  given  in 
small  quantities,  and  stimulants  if  necessary.  Washing  out  the  stom- 
ach frequently  allays  the  vomiting.  This  is  best  done  with  a  tube, 
but  in  older  children  it  is  apt  to  cause  excitement  and  does  more 
harm  than  good.  With  younger  children  the  process  is  easily  carried 
out.  A  glass  of  warm. water  will  sometimes  accomplish  the  same  pur- 
pose. Often  a  cup  of  hot  water  sipped  slowly  will  relieve  the  nausea. 
Equal  parts  of  lime-water  and  cinnamon-water  form  a  mixture  that 
is  very  useful  for  irritable  stomach. 

When  the  stomach  continues  irritable,  it  is  best  to  give  some  one  of 
the  liquid  beef  preparations.  Completely  peptonized  skim-milk  may 
be  tried.     Human  milk,  especially  skimmed,  may  be  retained  when 


DIET  I\  DISEASES  OF  CHILDREN  33;i 

nothing  else  is.  In  other  cases  barley-  or  rice-water  is  retained. 
Malted  milk  is  often  of  great  service,  and  the  malted  foods,  which  are 
ordinarily  mixed  with  milk,  may  be  given  mixed  with  water  instead. 
Kumiss  may  sometimes  be  retained  when  other  foods  are  rejected. 
Animal  broths  free  from  fat  are  also  useful.  If  vomiting  is  persistent, 
gavage  should  be  resorted  to.  If  any  one  of  the  foods  mentioned 
seems  to  augment  the  number  of  stools,  another  should  be  subsituted. 

As  the  child  improves,  malted  milk,  one  of  the  malted  foods,  or 
equal  parts  of  milk  and  barley-  or  rice-gruel  boiled  together,  may  be 
given.  Eskay's  food  is  valuable  in  the  convalescence  from  diarrheal 
diseases.  Raw  or  very  rare  scraped  meat  may  be  given,  but  this  is 
apt  to  cause  very  offensive  stools.  Eggs  cooked  in  various  ways  and 
later  plain  boiled  milk  may  be  given.  Zwieback,  crackers,  and  toast 
may  be  added  cautiously  to  the  dietary,  and  the  return  to  the  normal 
allowance  be  made  gradually.  Great  care  should  always  be  exercised 
during  and  after  convalescence,  as  dietary  errors  are  apt  to  be  fol- 
lowed by  speedy  and  severe  relapses.  Fresh  fruit,  coarse  vegetables, 
and  all  irritating  and  indigestible  articles  should  be  prohibited. 

Chronic  Ileocolitis. — The  dietary  of  a  child  with  this  disease  is  not 
easily  constructed.  The  foods  directed  for  acute  cases  are  all  useful, 
and  a  dietary  can  be  formulated  from  them.  The  effect  of  any  food 
on  the  stools  should  be  watched,  but  observations  should  not  be  made 
in  the  presence  of  the  patient,  as  children  of  four  years  or  more  may 
become  very  morbid  from  watching  frequent  examinations  of  their 
stools. 

The  predigested  foods,  such  as  the  beef  preparations,  peptonized 
milk,  and  the  like,  are  among  the  most  valuable  articles  of  diet  in 
these  cases,  but  barley-  or  rice-gruel,  with  or  without  milk,  and  eggs 
may  also  be  used.  Malted  milk  and  the  malted  foods  are  of  service 
at  times.  Alcohol,  in  the  form  of  whisky,  brandy,  port  or  sherry,  and 
in  whatever  shape  it  is  most  palatable,  may  be  given. 

Inunctions  with  cocoanut  oil  or  cocoa-butter  are  useful  in  pro- 
moting nutrition.  A  change  of  air  is  often  followed  by  excellent 
results. 

Chronic  Intestinal  Indigestion. — Under  this  head  may  be  included 
the  ordinary  form  of  chronic  intestinal  indigestion,  as  well  as  such 
special  forms  as  starch  indigestion  and  the  so-called  mucous  disease. 

Where  the  cooperation  of  the  mother  or  nurse  can  be  secured,  the 
results  of  treatment  are  very  satisfactory.  If  the  diet  can  not  be 
controlled  absolutely,  it  is  difficult  or  impossible  to  accomplish  much 
in  these  cases. 

Chronic  intestinal  indigestion  occurs  at  all  ages.  In  young  infants 
it  is  frequently  due  to  improper  feeding,  and  disappears  when  the 
child  is  put  upon  a  proper  diet.  It  may  be  seen  in  both  breast-fed 
and  bottle-fed  babies.  In  breast-fed  infants  it  is  fretjuently  caused 
by  an  over-rich  milk,  in  which  case  a  simpler  diet  for  the  mother 
with  exercise  out  of  doors  will  be  all  that  is  required.     (See  Man- 


334  INFA2fT  FEEDING 

agement  of  Nursing  Mothers.)  In  other  instances,  where  the  mother 
hcis  been  taking  various  articles  in  order  to  increase  the  flow  of  milk, 
a  return  to  a  proper  regimen  brings  relief.  In  still  other  cases  the 
child  is  nursed  too  often  or  too  long.  The  disease  may  come  on  as 
the  result  of  allowing  the  child  to  sleep  all  night  at  its  mother's 
breast,  with  the  consequent  frequent  and  irregular  night  feedings. 
In  another  troublesome  class  of  cases  no  cause  can  be  made  out.  In 
these,  if  the  condition  persists  and  the  child's  general  health  is  af- 
fected, weaning  should  be  considered ;  when,  however,  the  child  con- 
tinues to  thrive  and  the  condition  can  not  be  relieved,  nursing  may  be 
allowed  to  continue;  frequently  these  cases  recover  in  a  short  time. 

When  the  disease  occurs  in  bottle-fed  babies,  the  child  has  usually 
been  given,  for  a  considerable  period,  a  food  too  high  in  one  or  more 
of  the  food  elements.  (This  subject  has  been  discussed  under  Infant 
Feeding,  to  which  section  the  reader  is  referred.)  Another  frequent 
cause  in  bottle-fed  babies  is  the  use  of  a  proprietary  food  unsuited  to 
the  age  or  condition  of  the  child,  or  the  use  of  improper  articles  of 
diet,  especially  starches  and  sugars. 

Sugar  and  starchy  food  in  excessive  quantities  is  a  factor  in  the 
causation  of  this  disease  that  is  often  overlooked.  Careful  questioning 
frequently  brings  out  the  fact  that  sweets  of  various  kinds  have  been 
given  to  the  infant  by  indulgent  parents  or  friends.  Periodic  at- 
tacks of  vomiting  and  pain  or  of  malaise  and  discomfort,  analogous 
to  the  bilious  attacks  of  older  individuals,  maj-  usually  be  relieved 
by  reducing  the  carbohydrates  to  a  minimum.  These  attacks  are 
occasionally  so  severe  and  misleading  as  to  give  rise  to  the  diagnosis 
of  malaria,  tuberculosis,  typhoid  fever,  and  many  other  diseases,  even 
by  competent  physicians.  In  almost  every  instance  a  complete  cure 
can  be  quickly  brought  about  by  dietetic  means  alone. 

Between  one  year  and  eighteen  months  it  is  common  for  mothers  to 
desire  to  increase  the  diet  of  their  children.  Milk  should  always 
form  the  basis  of  the  diet,  and  if  other  articles  disagree,  a  diet  of 
milk  and  broths  exclusively  may  bring  about  a  state  of  perfect  com- 
fort. 

In  Older  Children. — The  management  of  these  cases  is,  as  a  rule, 
quite  satisfactory.  They  require  individual  study,  however,  for  in 
one  case  the  fat  may  be  the  cause  of  the  trouble,  in  another  it  may 
be  the  curd  in  the  milk,  and  in  still  another  the  earbohj^drates  may 
be  the  disturbing  element.  The  diet  should  aim  to  give  the  intestine 
as  little  work  to  do  as  possible.  To  this  end,  the  carbohydrates  should 
be  discontinued  altogether  at  first;  and  when  they  are  begun  again, 
it  should  be  cautiously,  and  the  effect  should  be  carefully  watched. 
The  fats  should  be  greatly  reduced  or  even  omitted  altogether.  Pro- 
tein should  be  given  in  as  digestible  a  form  as  possible,  and  peptonized 
if  it  causes  indigestion. 

In  severe  cases  the  child  may  be  fed  upon  peptonized  skim-milk. 
This  may  be  completely  or  partially  peptonized,  as  circumstances  de- 


DIET  IN  DISEASES  OF  CHILDREN  335 

mand.  It  should  be  given  in  moderate  quantities  every  two  hours. 
Kumiss  may  be  used  to  vary  the  diet,  and  buttermilk,  if  the  child  will 
take  it,  forms  an  agreeable  change.  Liquid  predigested  beef  prepara- 
tions may  also  be  used.  Chicken  or  veal  broth  from  which  the  fat  has 
been  removed  may  likewise  be  given. 

Bare  or  raw  meat  is  usually  well  borne.  It  should  be  scraped  fine 
and  given  immediately  after  preparing  it.  If  desired,  it  may  be 
rolled  into  small  balls.  Of  this,  two  or  three  tablespoonfuls  are  an 
average  daily  allowance.  Beef  is  to  be  preferred,  but  mutton  may  be 
permitted.  Dish  gravy  from  which  the  fat  has  been  skimmed  may 
be  given,  and  may  be  served  in  a  green  glass  if  the  color  of  the  fluid 
excites  disgust. 

After  a  week  or  two,  if  improvement  has  begun,  a  malted  food  may 
be  added  to  the  milk.  Eskay's  Food  is  of  particular  value  in  these 
intestinal  cases,  and  is  occasionally  well  borne  when  even  peptonized 
milk  is  not.  The  food  should  be  given  at  regular-timed  intervals ; 
and  if  one  meal  is  not  well  borne,  nothing  should  be  given  until  the 
next  regular  feeding-time.  Absolutely  no  food  should  be  given  be- 
tween meals.  Water  may  be  allowed  as  desired,  but  should  be  given 
between  meals,  so  as  not  to  interfere  with  digestion.  Four  meals  a 
day,  or  even  but  three,  should  be  all  that  is  permitted. 

As  improvement  sets  in  the  diet-list  may  be  extended  to  include 
junket  and  simple  dishes  prepared  with  milk  or  eggs  or  both  together. 
Then  a  little  zwieback,  toast,  or  thin  crackers  may  be  allowed.  Of 
the  meats,  chicken,  beef,  and  mutton  are  the  most  preferable.  The 
white  meat  of  boiled  or  roast  fish  may  be  allowed,  without  any  rich 
sauces,  however,  and  oysters  may  be  given  in  season.  The  dietary 
must  not  be  increased  too  rapidly,  and  it  is  well  to  allow  a  month 
to  go  by  before  making  any  decided  changes. 

Cereals  may  be  added  in  the  form  of  a  little  very  thoroughly  cooked 
rice  or  barley  in  the  broth.  Later,  green  vegetables,  of  which  the  best 
are  spinach,  cauliflower  tops,  asparagus-tips,  or  thoroughly  stewed 
celery,  may  be  given. 

If  improvement  goes  on,  well-cooked  cereals,  such  as  rice  and  grits, 
may  be  given  at  breakfast.  They  should  be  thoroughly  cooked  and 
strained  if  necessary.  Oatmeal  should  not  be  given  until  the  diges- 
tion has  become  normal.  Well-cooked  macaroni  makes  a  pleasant 
change,  and  fresh-fruit  juices  may  be  given,  preferably  an  hour  before 
meals.  Of  the  latter,  orange-juice  is  best,  but  in  season  the  juice  of 
fully  ripened  peaches  or  grapes,  without  skins  or  seeds,  may  be  given. 

As  improvement  progresses,  cream  and  butter  may  be  added.  A 
very  small  portion  of  well-baked,  mealy  potato  may  be  given,  with 
the  addition  of  cream.  Potatoes  should  never  be  given  early  in  the 
treatment,  and,  when  this  food  is  added  the  effect  should  carefully  be 
watched. 

The  dieting  must  be  continued  for  a  year  or  more,  and  for  several 
years  later  the  diet  must  be  carefully  supervised.     This  must  be  in- 


336  INFANT  FEEDING 

sisted  upon,  and  is  usually  not  a  difficult  matter  after  improper  feed- 
ing has  brought  on  a  relapse.  Although  every  care  should  be  taken 
to  avoid  relapses,  when  they  occur  they  form  the  most  powerful  in- 
centive for  vigilance  on  the  part  of  the  nurse  or  mother. 

Directions  as  to  quantities  and  preparation  of  food  and  the  hours 
of  feeding  should  be  written  out,  and  a  careful  record  kept  of  what 
the  child  takes,  and  the  quantity,  as  well  as  the  number  and  character 
of  the  stools.  By  this  plan  it  is  frequently  easy  to  detect  idiosyncra- 
sies, and  to  learn  what  agrees  and  what  disagrees  with  the  particular 
patient  in  charge. 

A  point  of  no  small  importance  is  the  avoidance  of  starvation. 
Unless  a  physician  thoroughly  understands  the  feeding  of  infants  he 
may  starve  a  child  and  render  it  weak,  anemic,  and  unable  to  with- 
stand the  effects  of  the  disease.  Cases  that  have  been  set  down  as 
intractable  catarrh  of  the  intestine  are  often  merely  the  results  of 
starvation  or  due  to  an  unsuitable  milk  mixture.  In  such  cases,  with 
return  to  a  rational  diet  recovery  promptly  follows. 

Intolerance  to  Fat. — This  is  frequentlj^  noted  in  infants  and  also 
in  older  individuals.  In  infants  it  may  produce  vomiting  one  or 
two  hours  after  feeding,  or  the  symptoms  may  be  largely  referable 
to  the  intestines.  In  this  case  there  are  colic  and  large  white  stools, 
or  sometimes  thin  greenish  stools,  which  are  very  irritating  to  the 
skin.  Sooner  or  later  there  is  a  marked  disturbance  of  general  health, 
and  the  children  are  usually,  though  not  always,  pale  and  thin.  In 
older  children  an  interesting  and  often  wrongly  interpreted  symptom 
complex  may  be  noted  when  too  much  fat  has  been  added  to  the  diet. 
This  may  be  done  on  the  advice  of  the  physician,  who  orders  a  thin 
child  to  have  an  abundance  of  cream,  butter,  and  oil,  with  the  idea 
of  building  it  up.  Older  children  showing  fat  intolerance  are  gen- 
erally, though  not  always,  pale,  thin,  and  in  general  bad  health. 
They  are  irritable,  and  often  have  marked  circles  under  the  eyes,  and 
the  breath  has  a  very  foul  odor.  Often  this  symptom  is  the  one  for 
which  relief  is  sought.  In  other  children  there  may  be  marked  gastric 
and  intestinal  disturbance,  and  attacks  of  colicky  diarrhea.  Excessive 
quantities  of  fat  may  be  found  in  the  stools.  Another  interesting 
class  of  cases  are  those  in  which  there  is  recurrent  vomiting  due  to 
excessive  fat.  The  diagnosis  can  usually  be  made  by  a  careful  study 
of  the  diet  and  stools,  and  confirmed  by  the  effect  of  treatment,  which 
consists  in  cutting  down  the  amount  of  fat  in  the  diet.  As  in  older 
individuals,  there  is  a  lack  of  absorption  of  fats  when  there  is  icterus. 

Constipation. — Chronic  constipation  is  the  cause  of  more  worry 
and  distress  than  almost  any  other  condition.  In  order  to  relieve  it, 
the  diet  must  be  regulated  carefully  and  correct  habits  be  formed. 
The  formation  of  correct  habits  is  of  as  much  importance  as  the  diet 
in  the  prevention  and  correction  of  this  condition.  Infants  as  young 
as  three  months  of  age  may  be  taught  to  have  a  stool  regularly  by 
placing  them  upon  a  small  chamber  at  a  stated  hour.     In  older  chil- 


DIET  IX  DISEASES  OF  CHILDREN  337 

dreii  a  fixed  time  should  be  set  for  the  daily  visit  to  the  closet.  The 
best  time  for  this  is  just  after  a  meal,  preferably  breakfast,  as  at  this 
time  there  is  a  wave  of  peristalsis  of  which  advantage  may  be  taken. 

Constipation  is  quite  common  in  breast-fed  infants,  and  is  usually 
due  to  the  child's  getting  a  minimum  amount  of  food  or  a  milk  that 
is  low  in  fat  and  generally  high  in  protein.  The  quality  of  the 
mother's  milk  should  be  improved  if  possible,  following  the  directions 
previously  laid  down.  Between  the  nursings  the  infant  should  be 
given  water.  If  this  is  not  sufficient  and  the  mother's  milk  is  found 
deficient  in  fat,  1  or  2  teaspoonfuls  of  cream  may  be  added  to  each 
nursing,  or  cod-liver  or  olive  oil  may  be  given  in  half  to  teaspoouful 
doses.  An  efficient  change  in  the  diet  consists  in  giving  1  or  2  tea- 
spoonfuls  of  thoroughly  cooked  oatmeal.  This  should  be  of  about 
the  consistence  of  cream,  well  sweetened  with  sugar,  and  strained  if 
necessary.  This  may  be  given  once,  twice,  or  oftener  a  day,  as  the 
case  requires,  and  is  best  given  with  a  nursing.  Orange-juice  well 
sweetened  may  be  prescribed  in  doses  of  a  teaspoonful  to  a  tablespoon- 
ful,  given  an  hour  or  so  before  a  nursing.  Stewed  prune-juice  may 
be  used  in  the  same  manner,  and  in  season  any  fruit-juice  from  per- 
fectly fresh  ripe  fruit  may  be  utilized.  Bottled  or  fresh  grape  juice 
is  often  of  marked  benefit.  The  very  acid  fruits  should  not  be  al- 
lowed. A  teaspoonful  of  a  malted  food  prepared  with  barley  may  be 
given,  and  small  amounts  of  the  thick  sweet  malt  extracts  may  be 
used  with  advantage.  Mellin's  Food  may  be  used  to  sweeten  the 
food  in  place  of  sugar.  Care  should  be  taken  not  to  disturb  the  in- 
fant's digestion  by  the  too  frequent  use  of  any  of  the  articles  just 
mentioned,  or  by  the  use  of  too  large  quantities ;  only  one  article 
should  be  tried  at  a  time.  If  these  means  fail,  drugs  or  suppositories 
must  temporarily  be  resorted  to.  It  should  be  borne  in  mind  that  the 
constant  use  of  drugs  may  defeat  any  efforts  along  dietetic  lines. 

In  bottle-fed  babies,  if  the  milk  is  modified  properly,  constipation 
will  usually  be  overcome.  If  relief  is  not  obtained  by  this  means, 
measures  similar  to  those  directed  for  breast-fed  babies  must  be  taken. 
A  small  quantity  of  barley-  or  oatmeal-water  may  be  mixed  with  the 
milk  or  a  malted  food  added  to  it. 

The  use  of  fresh  green  and  other  vegetables  boiled  and  mashed 
or  passed  through  a  sieve  will  be  found  useful.  (See  Vegetable 
Purees  in  Infant  Feeding).  Graham  or  oatmeal  crackers  moistened 
with  milk  are  useful  and  judiciously  chosen  foods  rich  in  cellulose, 
such  as  cauliflower,  mashed  potato,  boiled  mashed  strained  turnips, 
and  particularly  oatmeal,  will  be  found  useful.  Care  should  be  taken 
not  to  upset  the  digestion  by  giving  too  much  or  starting  too  ab- 
ruptly. 

In  older  children,  fed  according  to  the  rules  already  laid  down, 
constipation  is  not  so  frequent,  but  when  the  diet  is  neglected  and  the 
child  allowed  to  do  as  it  pleases,  it  is  a  very  common  complaint.  A 
glass  of  water,  either  hot  or  cold,  should  be  given  an  hour  before 

22 


338  INFANT  FEEDING 

breakfast.  Cream,  as  well  as  water,  should  be  added  to  the  milk. 
Barley-  or  oatmeal-water  may  at  times  be  added  to  the  milk  with 
benefit.  Meat  broths  are  laxative  in  their  effects  when  added  to  this 
diet.  Under  eighteen  months  fruit-juices,  or  after  that  time  perfectly 
ripe  sound  fruit,  especially  when  taken  an  hour  before  a  meal,  is  very 
serviceable.  Figs  and  prunes  stewed  together  are  helpful,  as  are 
oatmeal  and  bread  made  from  unbolted  flour.  In  much  older  chil- 
dren the  management  is.  similar  to  that  recommended  for  adults. 

Holt  manages  an  average  case  of  chronic  constipation  in  a  child  of 
four  years  of  age  as  follows:  "Massage  for  eight  minutes,  morning 
and  night ;  the  juice  of  half  an  orange  and  a  glass  of  Vichy  imme- 
diately upon  rising ;  a  breakfast  of  oatmeal,  with  one  ounce  of  cream, 
dried  bread  with  butter,  an  egg,  half  glass  of  milk  with  cream  and 
water  added ;  a  dinner  of  soup,  one  starchy  vegetable — i.  e.,  potato 
with  cream — and  one  green  vegetable,  beefsteak,  baked  apple  or 
prunes,  dried  bread  and  butter,  and  water  to  drink ;  for  supper,  cream 
toast,  egg,  dried  bread  and  butter  or  Graham  crackers,  half  glass  of 
milk  with  cream  and  water  added;  a  suppository  containing  nux 
vomica  and  hyoscyamus  at  bedtime." 

Inanition. — Inanition  is  a  term  loosely  applied  to  various  condi- 
tions ;  it  should,  however,  be  restricted  to  those  cases  of  acute  starva- 
tion coming  on  in  very  early  life.  It  is  characterized  by  a  loss  of 
weight,  and  usually  by  fever  as  well,  and  the  condition  is  not  infre- 
quently mistaken  for  some  other  disease.  It  follows  abstinence  from 
food,  such  as  occurs  in  those  cases  where  infants  are  abandoned  on 
door-steps,  or  are  grossly  neglected  and  starved.  Other  causes  are 
nursing  at  a  dry  or  nearly  dry  breast,  in  which  case  the  child  seizes 
the  nipple  eagerly  and  after  several  vigorous  attempts  at  sucking 
drops  the  nipple,  cries,  and  seems  to  be  uncomfortable.  Gross  errors 
in  feeding,  as  where  a  child  is  given  a  food  absolutely  unsuited  to 
its  needs,  may  also  bring  about  this  condition.  It  may  occur  in  in- 
fants with  enfeebled  digestion — either  those  congenitally  debilitated 
or  those  rendered  so  by  disease.  Sudden  changes  in  food  may  also 
occasionally  cause  it. 

In  the  management  of  these  cases,  which  is  apt  to  be  difficult,  the 
same  general  routine  should  be  followed  as  is  suggested  for  marantic 
babies.  If  possible,  a  wet-nurse  should  be  secured.  Holt  advises  that 
the  breast-milk  be  diluted  with  an  equal  volume  of  water  or  of  lime- 
water.  He  also  suggests  that  if  there  is  diarrhea,  the  milk  be  pumped 
from  the  breasts  and  the  cream  removed.  The  proportion  of  fat  may 
gradually  be  increased.  AVhen  a  wet-nurse  can  not  be  secured,  the 
child  should  first  be  given  very  dilute  mixtures,  or  a  milk  so  modified 
as  to  be  indicated  for  a  child  much  younger  than  the  one  in  hand. 
These  milk  mixtures  should  be  partially  or  completely  peptonized. 
The  authors  have  used  weak  milk  mixtures  to  which  Peptogenic  Milk 
Powder  has  been  added,  with  benefit.  These  may  be  given  by  means 
of  a  bottle,  or  if  the  child  will  not  suck,  by  means  of  a  medicine-drop- 


DIET  ly  DISEASES  OF  CHILDREN  339 

per  or  spoon,  or  by  gavage  if  necessary.  In  all  eases  in  which  a  child 
refuses  to  take  food  a  stomach-tube  should  be  passed  in  order  to 
ascertain  if  the  esophagus  is  patent  or  not,  and  the  fauces  should  also 
be  examined  carefully  both  by  sight  and  by  touch. 

If  the  peptonized  milk  is  not  well  borne,  predigested  beef  prepara- 
tions, diluted  condensed  milk,  malted  or  farinaceous  foods,  albumin- 
water,  barley-water,  in  fact,  any  form  of  food  that  can  be  given,  may 
be  tried.  Those  just  mentioned  are,  however,  the  most  apt  to  prove 
useful.  Water,  if  needed,  may  be  given  by  subcutaneous  injection 
or  by  the  rectum,  a  normal  salt  solution  being  best  for  this  purpose. 

Children  very  small  at  birth  are  best  treated  in  the  same  manner 
as  premature  babies.  Inanition  in  older  infants  may  often  be  com- 
bated by  allowing  food  that  would  not  be  permitted  under  ordinary 
conditions.  Solid  food  suited  for  a  child  twice  the  age  of  the  one 
under  treatment  sometimes  succeeds  when  everything  else  has  failed. 

Marasmus. — Marasmus,  known  also  under  the  names  of  "wasting 
disease  of  children,''  athrepsia,  and  simple  atrophy,  is  best  described 
as  a  condition  of  pernicious  atrophy.  The  term  inanition  should  be 
used  only  for  those  cases  of  acute  starvation,  with  their  characteristic 
symptoms  and  causes,  occurring  in  infants. 

Atrophy  in  infants  may  be  divided  into  two  classes :  The  primary 
cases,  where  the  cause  is  unknown,  and  the  secondary  cases,  or  those 
that  follow  definite  pathologic  conditions.  The  dividing-line  can  not 
at  present  definitely  be  drawn.  All  cases  occurring  in  the  course  of 
the  easily  recognized  diseases  may  at.  once  be  placed  in  the  group 
of  secondary  cases — those  following  tuberculosis,  for  example.  Most 
cases  seen  clinically  occur  in  infants  who  have  not  had  proper  food 
and  care.  Some  authors  would  place  these  in  the  list  of  secondary 
cases,  and  consider  them  from  another  standpoint,  regarding  the 
process  of  nutrition  as  twofold — digestion  as  the  first  step,  and  as- 
similation as  the  second.  Under  the  head  of  primary  atrophy  these 
authors  would  place  only  those  cases  in  which  the  second  factor  was 
at  fault ;  or,  in  other  words,  those  cases  receiving  proper  care  and  a 
physiologically  correct  diet.  This  division  is,  for  practical  purposes, 
useless ;  and  since  we  lack  definite  information  on  the  subject,  the 
cases  should  be  divided,  from  a  pathologic  basis,  into  those  that  exhibit 
lesions  of  definite  diseases,  and  those  in  which  there  are  no  special  and 
constant  lesions  beyond  wasting  of  the  muscles  and  body-fat  and 
atrophy  of  the  thymus  gland. 

If  care  is  taken  to  exclude  tuberculosis  as  well  as  other  diseases, 
the  diagnosis  of  the  condition  presents  no  especial  difficulties. 

In  some  instances  the  cause  of  the  disease  can  not  be  made  out, 
whereas  in  other  instances  it  is  traceable  to  improper  feeding,  lack 
of  care,  insufficient  exercise,  and,  most  important,  lack  of  fresh  air 
and  sunshine. 

When  cases  are  seen  reasonably  early  and  if  the  causes  can  be 
recognized  and  remedied,  the  outlook  is  good.     In  private  practice 


340  INFANT  FEEDING 

cases  among  the  well-to-do  usually  do  well.  If  seen  late,  the  prognosis 
is  nearly  hopeless,  and  in  asylums  and  infant  homes  the  outlook  is 
most  gloomy.  If,  when  the  infant  is  first  seen,  digestive  disturbances 
are  present  and  can  be  corrected  by  dietary  measures,  the  outlook  is 
more  hopeful  than  in  those  cases  where  sufficient  food  is  taken  and 
digested  but  the  child  nevertheless  continues  to  waste.  In  the  really 
typical  forms  this  is  the  case,  and  the  disturbance  seems  to  be  due 
to  improper  utilization  of  the  food.  Sufficient  food  may  be  taken 
and  enough  digested  and  absorbed,  but  in  the  burning-up  of  the  food 
in  the  body  some  change  takes  place  that  permits  it  to  be  disposed  of 
without  properly  nourishing  the  system. 

The  treatment  of  these  cases  is  essentially  dietary  and  hygienic, 
and  either  measure  alone  must  fail.  The  child  must  be  kept  warm, 
and  in  a  well-aired  room ;  if  possible,  it  should  be  given  sun-baths 
and  be  taken  into  the  fresh  air.  In  proper  seasons  of  the  year  it 
should  be  out-of-doors  most  of  the  time,  preferably  in  the  country. 
The  child 's  body  should  be  massaged  gently  once  or  twice  daily,  using 
gentle  friction  and  a  lubricant  such  as  cocoa-butter  or  cocoanut  oil. 
The  rubbing  movements  should  always  be  directed  toward  the  heart, 
so  as  to  facilitate  circulation.  The  child  should  be  carried  about 
and  coddled  as  much  as  possible,  for  many  of  these  infants  are  starv- 
ing for  want  of  a  mother's  love  as  much  as  for  want  of  food.  The 
child  should  be  fed  while  lying  on  the  nurse's  lap  or  arm,  and  not 
as  it  lies  in  the  crib.  This  last  is.  of  course,  impracticable  in  many 
infant  homes  and  hospitals.  The  feeding  should  be  the  same  as  has 
been  suggested  under  the  heading  of  Loss  of  Weight.  Of  drugs, 
creosote,  best  given  in  the  form  of  Liquid  Beef  Peptonoids  with  creo- 
sote, carbonate  of  creosote,  or  carbonate  of  guaiacol,  is  the  most  useful 
in  the  condition,  nux  vomica  and  alcohol  also  being  of  service. 

Nursing  Homes  for  Marasmus  Cases. — If  homes  could  be  established 
for  the  nursing  and  care  of  marantic  babies,  the  infant  mortality 
from  this  disease  would  be  greatly  diminished.  This  nursing-home 
plan  has  been  carried  into  effect  in  some  of  the  cities  of  Germany. 
In  these  institutions  women  who  have  recently  been  delivered  are 
cared  for  on  condition  that  they  nourish  one  or  more  infants.  The 
quantity  of  milk  secreted  by  these  women  under  the  constant  stimula- 
tion of  several  sucking  children  is  remarkable. 

It  must  be  remembered  that  a  large  percentage  of  the  cases  of 
marasmus  occur  in  children  who  have  been  abandoned  by  their 
mothers  at  birth.  If  a  child  is  nursed  at  the  breast  for  two  or  four 
weeks,  it  is  more  likely  to  improve  and  live  than  if  it  is  taken  from 
the  breast  immediately  and  given  uncertain  milk  mixtures. 

Malnutrition. — Malnutrition  is  a  term  applied  to  cases  of  defective 
nutrition  that  run  a  more  chronic  course  than  those  suffering  from 
inanition  or  marasmus.  It  occurs  in  infants  and  in  older  children. 
In  the  former  the  management  is  similar  to  that  of  marasmus ;  in  the 
latter,  the  same  general  rules  apply.     The  life  of  the  child  must,  so 


DIET  IX  DISEASES  OF  CHILDREN  :U1 

far  as  possible,  be  carefully  regulated,  and  an  abundance  of  fresh 
air  and  sunshine,  together  with  appropriate  exercises  and  intervals 
of  undisturbed  rest,  enjoined.  The  diet  is,  however,  the  most  im- 
portant element  in  the  treatment.  The  food  should  be  plain  and 
wholesome,  carefully  prepared,  and  given  at  regular  but  not  too 
frequent  intervals.  In  some  cases  it  may  be  found  advisable  to  give 
smaller  meals  at  shorter  intervals.  The  food  should  be  such  as  is 
recommended  for  normal  children ;  a  list  of  these  articles  is  given 
elsewhere,  where  the  details  of  the  feeding  will  also  be  found. 

Feeding  after  Intubation. — Usually  this  is  accomplished  with  but 
little  or  no  difficulty,  but  in  some  instances  swallowing  m-Aj  at  first 
be  difficult,  and  in  these  cases  semi-solids,  such  as  junket,  soft-boiled 
eggs  or  a  very  light  omelet,  wine-jelly,  or  milk-toast,  may  be  sub- 
stituted for  the  liquid.  If  the  semisolids  fail,  it  has  been  suggested 
that  the  child  be  placed  with  its  head  lower  than  its  body,  and  that 
nourishment  be  given  while  in  this  position.  As  soon  as  the  child 
learns  to  swallow  with  the  tube  in  place  the  usual  light  diet  may  be 
given. 

Enuresis. — Besides  the  training  and  the  medicinal  treatment,  a 
plain,  nutritious  diet  is  of  great  service  in  these  cases.  In  the  major- 
ity of  cases  of  nocturnal  enuresis,  on  questioning  it  will  be  found 
that  the  children  have  been  getting  large  quantities  of  coifee  or  tea, 
or  that  large  amounts  of  water  have  been  taken  during  the  evening,  or 
that  the  bladder  has  not  been  emptied  before  going  to  bed.  In  these 
cases  the  treatment  is  obvious,  and  consists  in  excluding  coffee,  tea, 
and  stimulating  foods  (spices  and  the  like),  and  in  limiting  the 
amount  of  fluid  taken  after  four  in  the  afternoon.  Much  can  be 
done  by  proper  training.  When  dependent  upon  other  causes,  the 
treatment  must  be  directed  toM^ard  these  conditions. 

Rachitis  or  Rickets. — Rickets  is  a  disease  of  nutrition,  but  one 
that  is  not  well  understood.  ]\Iost  of  the  cases  occur  in  the  temperate 
zone,  and  southern  races  transported  north  seem  especially  predis- 
posed to  it.  It  is  very  common  among  the  negroes  of  Baltimore. 
The  authors  have  found  that  nearly  100  per  cent,  of  the  infants  in 
asylums  for  colored  children  were  aft'ected  with  rickets,  whereas  in 
similar  institutions  for  white  children  in  the  same  city  the  disease 
was  rare.  Italians  living  in  America  seem  predisposed  to  it,  and 
children  with  bad  hygienic  surroundings  are  more  apt  to  be  affected 
than  those  reared  amid  better  conditions.  It  is  a  disease  of  the  city. 
The  majority  of  the  cases  occur  between  six  months  and  two  years 
of  age ;  it  is  not  often  seen  in  breast-fed  children  unless  lactation  has 
been  continued  for  too  long  a  period.  Holt  states  that  among  the 
Italians  in  New  York  City  it  is  not  uncommon  to  find  it  in  children 
who  are  breast-fed. 

Rickets  may  be  produced  experimentally  in  animals,  as  has  been 
proved  by  Bland  Sutton  in  his  famous  experiments:  he  fed  lion 
whelns  on  an  exclusive  diet  of  raw  meat,  and  in  a  short  time  they 


342  IXFAyT  FEEDING 

developed  severe  rickets.  They  were  given  milk,  pounded  bones,  and 
cod-liver  oil,  and  in  three  months,  without  any  change  in  their  sur- 
roundings, they  were  cured.  Geurin  experimented  on  a  litter  of 
pups,  and  found  that  those  who  suckled  did  well,  .whereas  those  fed 
on  raw  meat  developed  rickets.  Numerous  experiments  of  this  kind 
have  been  conducted,  and  while  deductions  were  not  always  in  accord, 
they  tended,  nevertheless,  to  show  that  the  disease  may  be  produced 
by  withholding  milk  from  j'oung  animals  and  substituting  for  it  other 
articles  of  diet. 

In  children  fed  artificially  by  improper  methods  rickets  is  apt  to 
develop.  A  food  low  in  fats  is  especially  liable  to  produce  the  disease, 
particularly  if,  at  the  same  time,  the  proteins  are  also  deficient.  In 
such  a  diet  there  is  almost  certain  to  be  either  an  excess  of  the  car- 
bohydrates or  of  some  substance  unsuited  to  the  child's  digestion. 
Among  foods  that  cause  rickets  may  be  mentioned  some  of  the 
proprietary  foods  and  condensed  milk. 

The  lime  salts  are,  under  certain  conditions,  apparently  absorbed 
with  difficulty,  and  this  would  seem  to  be  the  case  when  the  food 
is  deficient  in  fat.  Hence  if  the  child's  diet  lacks  fat  or  if  the  lime 
salts  are  deficient,  the  bones  will  be  improperly  nourished.  It  has 
been  thought  that  this  was  due  to  an  excess  of  lactic  acid,  and  there 
are  a  number  of  other  theories  that  need  not  be  considered  here. 

Diet. — The  feeding  in  rickets  is  very  simple,  and  when  it  is  possible 
to  combine  with  it  outdoor  life  and  proper  care  and  nursing,  is  very 
efficient.  If  the  child  must  be  fed  artificially,  and  if  it  exhibits 
symptoms  that  are  suggestive,  such  as  sweating,  tenderness,  or  restless- 
ness at  night,  it  should  be  given  cream  or  cod-liver  oil  in  addition  to 
the  proper  diet.  In  this  way  the  disease  may  be  prevented.  When 
the  disease  has  developed,  the  child  should  be  placed  on  a  diet  suitable 
to  its  age,  as  suggested  in  the  section  on  the  Feeding  of  Infants;  the 
food  should  consist  in  fresh  milk,  eggs,  meat,  vegetables,  and  fruit. 
The  basis  of  the  diet  should  be  milk,  which  should  contain  4  per  cent, 
of  fat  if  the  child  can  digest  that  amount  and  is  old  enough  to  receive 
it.  Fat  in  some  form  must  be  supplied,  and  where  cream  is  not  well 
borne,  other  forms  may  be  tried  or  they  may  be  given  in  combination. 
Of  these,  cod-liver  oil  is  one  of  the  most  valuable,  and  may  be  given 
plain,  in  teaspoonful  doses  or  less,  so  as  not  to  disturb  the  digestion. 
If  the  plain  oil  is  not  well  borne,  it  may  be  given  in  the  form  of  an 
emulsion  or  with  malt  preparations.  Fat  bacon  browned  to  a  crisp 
by  dropping  small  pieces  in  boiling  grease  may  be  tried,  and  will 
often  agree  where  other  fats  do  not.  Bacon  fat  dropped  in  zwieback 
is  very  useful.  Butter  may  be  used,  but  in  large  amounts  this  may 
not  be  so  well  borne  as  the  other  forms.  Care  should  be  taken  that 
too  much  be  not  given  and  the  child's  digestion  disturbed  by  excess 
of  fat. 

Very  young  infants  with  rickets  do  best  on  human  milk  and  it 
should  be  secured  if  possible.     This  may  be  supplemented  with  cows' 


DIET  IN  DISEASES  OF  CHILDREN  343 

milk  if  necessary.  Vegetable  purees,  as  described  elsewhere  in  this 
volume,  should  be  given  as  well  and  scraped  meats,  and  fresh  or 
stewed  fruit  juice  added  to  the  diet.  The  carbohydrates  should  be 
limited,  but  not  excluded  from  the  dietary.  Soy  flour  added  to  the 
milk,  as  a  gruel  or  added  to  soups  or  cereals  supplies  additional  fat 
and  protein  in  a  form  readily  utilized. 

Intestinal  Infantilism. — Herter  has  described  a  form  of  dwarfs 
characterized  by  an  arrest  in  development,  with  a  flaccidity  of  the 
muscles,  but  with  a  good  grade  of  mental  power  and  normal  develop- 
ment of  the  brain,  as  is  evidenced  by  the  size  and  shape  of  the  head. 
There  is  also  intestinal  disturbance,  usually  with  large  fatty  stools 
and  a  distended  abdomen,  due  to  dilatation  of  the  colon.  There  is 
a  moderate  grade  of  anemia  and  rapid  onset  of  physical  and  mental 
fatigue.  He  believes  the  disease  to  be  due  to  non-absorption  of  calcium 
and  magnesium  and  to  the  restriction  of  carbohydrate  and  fats,  due 
to  poisoning  by  the  products  of  certain  forms  of  bacteria  not  normally 
present  in  the  intestinal  tract  of  young  children.  Those  cases  where 
care  can  be  given  usually  result  favorably,  and  after  ten  years  of 
age  the  growth  is  apt  to  be  rapid.  The  diet  is  entirely  a  matter  of 
experiment  in  each  individual  case.  Herter  advises  giving  large 
quantities  of  gelatin,  in  making  a  corresponding  decrease  in  carbo- 
hydrates and  fats,  and  increasing  protein  somewhat  over  that  or- 
dinarily taken.  Milk  is  borne  well  by  some,  poorly  by  other  cases. 
Buttermilk  and  fermented  milks  may  be  useful,  particularly  in  the 
later  stages.     Cod-liver  oil  is  of  great  service  in  these  cases. 


DIET  FOR  SPECIAL  CONDITIONS 

DIET  FOR  THE  AGED 

When  a  man  has  passed  his  fiftieth  year  his  diet  should  be  guarded. 
Dietary  indiscretions  or  a  too  plentiful  diet  will  result  either  in  the 
putting  on  of  flesh  and  the  consequent  discomforts  of  obesity  or  in 
the  development  of  gout  or  allied  affections.  In  considering  the 
diet  of  the  aged  the  old  dictum  that  a  man  is  as  old  as  his  arteries 
applies.  Age  can  not  always  he  counted  hy  years.  In  the  aged  there 
is  a  lessening  of  all  physical  activities.  The  old  man  takes  less  ex- 
ercise, has  diminished  powers  of  digestion,  and  is  less  able  to  absorb 
the  nutriment  he  has  digested.  His  circulation  is  poor  and  his  bowels 
are  constipated.  Degenerative  processes  have  taken  place  in  his  or- 
gans, and  he  is  more  apt  to  feel  the  effects  of  indiscretions  in  diet. 
For  these  reasons  the  diet  should  be  lighter  than  in  younger  years, 
and  the  amount  of  food  eaten  should  vary  with  the  needs  of  the 
individual.  The  food  should  be  of  an  easily  digestible  variety;  it 
should  be  given  in  smaller  quantities  at  a  time,  and  the  intervals 
between  meals  should  be  shortened.  If  there  is  a  tendency  to  obesity, 
food  that  is  apt  to  be  converted  into  fat  should  be  given  in  diminished 
amounts.  The  proteins  should  be  somewhat  lessened  from  time  to 
time.  The  practice  of  eating  heavy  suppers  late  at  night  and  of 
eating  between  meals  should  be  discontinued.  The  person  should 
learn  what  particular  articles  of  food  disagree  with  him,  and  refrain 
from  eating  foods  that  tend  to  cause  flatulence.  Yeo  suggests  that 
in  the  case  of  cooked  fruits  a  small  quantity  (about  a  teaspoonful  to 
the  pound  of  fruit)  of  sodium  bicarbonate  be  stewed  with  them,  to 
correct  the  acidity  that  causes  flatulence. 

In  the  aged  food  bears  a  close  relation  to  sleep.  A  cup  of  hot  milk, 
hot  toddy,  or  some  hot  liquid  food  taken  at  bed-time  will  often  over- 
come troublesome  sleeplessness.  A  few  sips  of  milk  or  a  mild  stimu- 
lant taken  during  the  early  morning  hours,  when  the  aged  are  apt 
to  awaken,  will  frequently  insure  sleep  again. 

Another  point  of  interest  is  the  question  of  mastication,  as  in  the 
aged  the  teeth  are  liable  either  to  be  lost  entirely  or  to  be  unfitted 
for  chewing.  The  rather  general  use  of  false  teeth  has  largely 
remedied  this,  but  it  may  be  necessary  to  point  out  that  farinaceous 
foods,  which  slip  easily  and  quickly  into  the  stomach,  must  either  be 
avoided  or  chewed  thoroughly,  so  as  to  prevent  indigestion  and 
flatulence.  When  the  teeth  are  lost,  or  are  defective,  the  food  should 
be  soft  in  character.  ]\Ieats  should  be  minced  or  cut  in  very  small 
pieces,  or  served  in  soft  stews,  and  hard  crusts  and  the  like  softened 

344 


DIET  FOR  THE  AGED  345 

by  soaking  in  milk,  tea,  or  eoti'ee.     Chewing  should  be  insisted  on  to 
insalivate  the  starchy  foods. 

The  digestive  abilities  of  aged  people  vary  greatly,  some  taking 
but  little  food  and  experiencing  difficulty  even  then,  while  others 
eat  a  great  deal  more  and  seem  to  enjoy  it  more  than  they  did  in 
their  younger  years.  This  latter  class  sometimes  pave  the  way  for 
various  difficulties  later  by  their  inordinate  eating.  When  they  have 
high  arterial  tension,  complain  of  giddiness,  flushing  after  meals,  and 
sometimes  of  nosebleed,  it  is  well  to  limit  the  amount  of  food  taken; 
the  same  is  true  where  there  is  a  tendency  to  obesity,  and  old,  obese 
persons  with  chronic  bronchitis  are  frequently  benefitted  by  a  care- 
fully adjusted  diet. 

All  complicated  dishes  are  best  avoided,  as  well  as  those  which  are 
highly  seasoned  or  strongly  flavored.  All  foods  which  are  liable  to 
cause  digestive  disturbance  or  toxemia  should  be  let  alone,  as  many  an 
old  person  is  carried  off  by  ptomaine  poisoning  caused  hy  some  gamey 
food,  which  one  with  a  vigorous  digestion  might  have  eaten  with  im- 
punity. Stale  canned  foods  should  not  be  taken  at  all,  and  articles 
of  diet  which  the  individual  knows  from  experience  will  cause  trouble 
should  be  avoided.  As  people  grow  older  it  is  a  general  rule  that 
they  crave  sweets  less,  and  that  sugars  are  less  easily  digested  and 
are  more  liable  to  cause  indigestion  and  flatulence.  Whenever  colic 
is  complained  of,  the  sweets  should  be  cut  down  in  quantity  or  avoided 
altogether,  and  if  this  does  not  remedy  it,  the  cause  should  be  sought 
either  in  farinaceous  foods  or  vegetables  of  the  cabbage  family,  or  the 
legumes. 

Foods  Suitable  for  the  Aged. — Milk  may  be  taken  in  all  forms 
when  easily  digested,  and  when  it  is  not  well  borne  the  addition  of 
warm  Vichy  or  warm  water  will  often  prove  helpful,  or  the  milk 
may  be  diluted  with  cereal  gruels,  or  have  sodium  citrate  (one  grain 
to  the  ounce)  added  to  it.  Beef -tea  is  often  useful  and  beef  juices 
may  also  be  used  if  desired.  Eggs,  lightly  cooked  or  beaten  up  with 
milk,  are  very  useful,  as  are  nutritious  soups,  such  as  chicken  or  fish 
purees,  mutton,  beef,  or  chicken  broth.  Young  and  tender  chicken, 
game  and  other  tender  meats,  and  good  quality  potted  chicken  or 
other  potted  meats  may  be  taken,  and  sweetbreads  are  easily  digested 
if  fresh  and  properly  prepared,  but  may  be  contraindicated  on  ac- 
count of  the  purin  nitrogen  contained.  White  fish,  such  as  sole, 
whiting,  smelts,  and  the  like,  are  all  suitable,  and  are  best  when  boiled. 
Crisp  grilled  bacon  is  relished  by  many. 

The  following  foods  are  all  suitable:  Bread-and-milk  made  with 
the  crumbs  of  stale  bread  and  without  lumps.  Porridge  and  oatmeal 
gruel.  Puddings  of  ground  rice,  tapioca,  arrow-root,  sago,  macaroni, 
with  milk  or  eggs,  and  flavored  with  spices  or  served  with  fruit- 
juice  or  jelly;  bread  and  butter,  the  bread  to  be  at  least  a  day  old; 
rusk,  to  be  soaked  in  tea  or  milk  and  water.     Prepared  foods,  con- 


346  DIET  FOR  SPECIAL  CONDITIONS 

sisting  of  predigested  starches;  at  this  age  the  digestive  ferments  are 
provided  scantily  by  the  digestive  organs,  and  soluble  carbohydrates 
are  valuable  for  maintaining  the  body-heat.  All  farinaceous  foods 
should  be  subjected  to  a  high  temperature  for  some  time  during  the 
cooking  process,  so  as  to  render  the  starch-granules  more  digestible. 

Vegetable  purees  of  all  kinds  may  be  taken  in  moderation — e.  g., 
potatoes,  carrots,  spinach,  and  other  succulent  vegetables.  Potatoes 
and  fresh  vegetables  are  a  necessity ;  if  omitted,  a  scorbutic  state  may 
be  engendered.  Stewed  celery  and  stewed  Spanish  or  Portugal  onions 
lend  variety  to  the  diet.  Stewed  or  baked  fruits,  fruit-jellies,  and 
the  pulp  of  perfectly  ripe  raw  fruits  in  small  quantity  may  be  taken. 

Dr.  George  S.  Keith,  in  his  Fads  of  an  Old  Physician,  gives  the 
following  account  of  his  diet  in  his  old  age : 

"For  breakfast  I  have  a  large  cup  of  tea,  with  milk  or  cream; 
brown  bread  from  two  to  three  ounces;  and  usually  one  and  a  half 
ounces  of  fish,  or  half  that  quantity,  and  that  very  rarely,  of  bacon. 
Sometimes  for  a  few  days  I  take  a  cup  of  coffee  with  half  milk,  but 
no  fish  or  bacon.  Lunch  is  a  cup  of  cocoa  or  chocolate,  if  the  weather 
be  cold ;  if  it  is  warm,  a  small  tumbler  of  milk,  about  six  ounces,  with 
the  same  quantity  of  bread  as  at  breakfast.  At  both  meals  I  use 
butter,  not  a  quarter  of  an  ounce,  and  quite  as  much  jelly  or  mar- 
malade. This  is  my  visual  lunch,  but  occasionally  instead  of  cocoa  I 
have  a  baked  apple,  or  some  prunes  with  milk,  or  strawberries  with 
cream  so  long  as  I  can  get  them,  or  very  rarely  vegetable  soup.  When 
I  have  no  milk  I  take  usually  a  morsel  (not  half  an  ounce)  of  cheese. 
At  4  p.  M.,  a  small  cup  of  tea,  and  sometimes  biscuit  or  cake.  For 
dinner,  at  7,  which  is  my  chief  meal,  I  have  soup,  from  peas,  lentils, 
potatoes,  celery,  carrots,  etc.,  the  first  two  made  with  no  meat  stock, 
and  the  others  with  a  little  from  lamb  or  a  bone;  or  fish  soup,  the 
only  animal  soup  I  indulge  in.  Fish,  mostly  white  deep-sea  fish 
direct  from  Montrose ;  of  this  I  take  no  more  than  three  ounces,  with 
a  potato  and  always  another  vegetable  fresh  from  the  garden.  If 
there  is  no  fish,  I  may  take  once  or  twice  a  week  an  ounce  or  two, 
certainly  not  more,  of  lamb,  game,  rabbit,  or  tripe ;  but  often  I  have 
neither  fish  nor  flesh.  The  dinner  ends  with  stewed  fruit  with  cream, 
or  pudding,  or  fruit  tart ;  of  these  I  take  a  fair  helping.  During  the 
winter  season,  instead  of  fruit  or  pudding,  I  often  have  celery,  with 
cheese,  oatcake  and  butter.  On  this  diet  I  enjoy  the  best  of  health, 
and  for  my  age  (seventy-eight)  am  up  to  a  fair  amount  of  exercise, 
walking  three  to  six  miles  daily  in  good  and  sometimes  in  bad  weather, 
and  usually  part  of  this  is  up  a  steep  road  with  a  rise  of  250  feet. 
The  only  confession  I  have  to  make  is  that  when  at  home  I  do  not 
rise  till  I  have  had  breakfast  and  read  the  newspaper.  This  is  a 
habit  I  have  recommended  to  many  approaching  my  own  age,  and 
those  who  have  tried  it  admit  that  they  are  stronger  for  the  rest  of 
the  day.     I  enjoy  breakfast  just  as  much  as  my  other  meals,  though 


DIET  FOR  THE  AGED  347 

I  never  feel  what  can  be  called  hunger,  and  have  not  done  so  for 
many  years.  I  could  omit  a  meal  at  any  time  without  discomfort. 
This  I  have  long  looked  upon  as  the  best  proof  of  perfect  digestion. 
During  very  warm  months  I  take  rather  less  bread  and  butter,  and  I 
do  not  try  to  make  this  up  by  taking  anything  else." 

DIET  DURING  PREGNANCY  AND  THE  PUERPERITJM 

Diet  during  Pregnancy. — Under  ordinary  circumstances  no  other 
diet  than  that  to  which  the  patient  is  accustomed  is  advisable.  The 
food  should  be  plentiful  and  nourishing.  All  highly  seasoned  food 
and  indigestible  articles  are  to  be  avoided,  as  are  all  articles  which  are 
known  to  disagree  with  the  patient.  When  there  is  a  morbid  craving 
for  unsuitable  things  the  patient  should  be  carefully  guarded  against 
indulging  her  appetite.  Special  diets  may  be  ordered  for  patients 
with  diabetes  or  heart  disease,  or  where  the  patient  is  gouty,  over-fat, 
anemic,  or  chlorotic.  Prochownick  ^  has  called  especial  attention  to 
these  conditions. 

Diet  in  Obesity  and  Pregnancy. — In  general,  the  diet  is  the  same 
as  advised  in  obesity.  This  should  be  combined  with  exercise,  either 
walking  or  light  gymnastics  and  massage,  which  should  not,  however, 
be  given .  over  the  abdomen.  The  diet  should  consist  of  meat,  fish, 
green  vegetables,  fruit,  and  a  small  allowance  of  carbohydrates. 
Prochow^nick  allows  4  or  5  ounces  (120-150  grams)  daily.  Fruit  is 
permitted,  but  should  not  be  eaten  in  too  large  quantities  nor  to  re- 
lieve thirst.  The  amount  of  fluid  should  be  restricted  to  a  pint  or 
a  pint  and  a  quarter  (500-600  ccm.).  Prochownick  allows  a  moderate 
amount  of  fat,  as  cream  and  butter,  but  not  fat  sauces.  Soups, 
sweets,  spirits,  and  preserves  are  to  be  avoided.  The  following  is  a 
sample  dietary  as  advised  by  Prochownick : 

7.00  A.M. — Four  ounces  (125  ccm.)  coffee  with  milk;  1^  ounces 
(40  grams)  bread  and  butter;  1  or  2  eggs;  a  little  fruit,  before  or 
after  this  40  to  45  minutes  walking. 

10.00  A.  M. — Massage  or  gymnastics. 

10.30  A.  M. — Fruit ;  1  egg ;  a  very  small  slice  of  bread  and  butter. 

Midday. — Roast  or  boiled  meat  or  fish ;  vegetables,  no  beets  or  peas ; 
salad;  cheese;  fruit;  4  ounces  (125  ccm.)  water  or  wine  and  water. 
No  afternoon  nap. 

4.00  P.M. — A  small  cup  of  coffee  or  tea,  not  over  3  ounces  (100 
ccm.)  ;  a  very  small  slice  of  bread  and  butter;  an  egg,  if  necessary. 
Walk  for  an  hour  or  an  hour  and  a  half. 

7.30  P.M. — Eggs  or  cold  meat;  4  to  6  ounces  (125-200  ccm.)  tea 
or  milk;  1  to  2  ounces  (40-60  grams)  bread;  butter;  fruit  or  salad. 

Thirst  is  usually  complained  of  early  in  the  treatment.  The  diet 
should  be  varied  to  suit  the  patient,  and  the  routine  should  be  so 
arranged  as  not  to  be  disagreeable  to  the  patient.     The  result  of  the 

1  Therapeutische  Monatschrift,  1901. 


348  DIET  FOR  SPECIAL  CONDITIONS 

lowered  amount  of  fluid  and  carbohydrate,  together  with  the  exercise 
and  massage,  is  to  reduce  the  amount  of  fat,  tone  up  the  system,  and 
to  produce  a  small  child,  so  that  labor  is  made  easier.  The  urine 
should  be  examined  from  time  to  time  and  the  patient  should  be 
weighed. 

Prochownick's  Diet  in  Pelvic  Contraction. — According  to  Pro- 
chownick,  Florschiitz,  and  others,  a  diet  deficient  in  carbohydrates 
and  fluids  will  result  in  a  small  child  without  otherwise  influencing 
its  development,  a  view  which  has  been  confirmed  by  Patton  in  Eng- 
land. The  diet  is  advised  in  women  who  have  previously  borne  very 
large  children  and  in  women  with  contracted  pelves.  In  the  latter, 
Prochownick  does  not  advise  the  diet  when  the  conjugata  vera  is 
below  8  cm.,  but  there  are  instances  where  the  child  was  born  alive 
and  well  with  the  conjugata  vera  7,  5,  7,  and  even  6.5  em.  By 
following  his  plan  difficult  labor  may  often  be  obviated,  and  even  the 
induction  of  premature  labor  unnecessary.  The  diet  may  be  begun 
ten  or  twelve  weeks  before  the  birth  is  expected,  and  after  the  first 
week  or  two  should  be  rigidly  followed.  Fraenkel  advises  beginning 
four  or  five  months  before  delivery.  The  average  diet  consists  of 
140  to  160  grams  of  protein,  80  to  130  grams  of  fat,  and  100  grams  of 
carbohydrates,  altogether  a  value  of  1800  to  2000  calories.  The  fluid 
should  be  restricted  to  about  500  ccm.  per  day.  Prochownick's  origi- 
nal diet  ^  is  as  follows : 

Breakfast. — One  small  cup  of  coffee  (3  oz.-lOO  ccm.)  ;  zwieback  or 
bread  (1  ounce-25  grams)  ;  a  little  butter. 

Dinner. — Any  kind  of  meat,  eggs,  or  fish,  with  little  sauce ;  green 
vegetables  prepared  with  fat  (as  cream)  ;  salad;  cheese. 

Supper. — Same  as  dinner,  with  1  to  II/2  ounces  (40-50  grams) 
bread,  and  as  much  butter  as  desired. 

Absolutely  forbidden. — Water,  soups,  potatoes,  desserts,  sugar,  and 
beer. 

Drink  per  day. — Red  or  moselle  wine,  9  to  12  ounces  (300-400 
ccm.). 

All  the  mothers  bore  this  diet  well  after  getting  used  to  it.  Thirst 
was  complained  of  during  the  early  part  of  the  treatment,  and  is 
especially  noticeable  in  fat  women.  Some  object  to  the  large  quan- 
tities of  animal  food,  but  this  is  overcome  by  the  use  of  green  vegeta- 
bles and  salads.  All  the  confinements  reported  have  been  easier  than 
on  previous  occasions,  even  when  the  child  was  large  and  fat,  and 
all  the  children  were  born  alive  even  though  the  majority  of  the 
mothers  had  had  previous  miscarriages.  The  children  were  lean  at 
birth,  with  the  bones  of  the  head  unusually  mobile.  The  children 
were  all  apparently  mature  in  every  way.  In  the  majority  of  in- 
stances the  child  gained  normally  after  birth,  and  the  diet  apparently 
had  no  bad  influence  on  lactation.     The  urine  should  be  examined 

1  Centralblatt  fiir  Gyndkologie,  1889,  33. 


DIET  DURING  PREGNANCY  AND  THE  PUERPERIUM  349 

regularly  and  the  amount  of  urea  estimated.  It  has  been  suggested 
that  such  a  diet  would  favor  eclampsia,  but  this  has  not  been  borne 
out  clinically. 

Diet  during  the  Puerperium. — Formerly  great  restrictions  were 
placed  on  the  diet  of  a  recently  delivered  woman,  thus  accounting, 
in  part,  for  the  loss  of  weight  that  has  been  noted.  If  there  is  no 
nausea  and  the  patient  desires  it,  a  cup  of  tea  or  a  glass  of  warm 
milk  may  be  given  soon  after  delivery. 

The  appetite  is  generally  poor  for  a  few  days  after  delivery,  but 
food  should  be  given  at  regular  intervals  not  too  widely  separated. 
The  ttrst  day,  milk,  milk-toast,  or,  if  desired,  dry  or  buttered  toast, 
with  coffee,  tea,  or  cocoa,  according  to  the  taste  of  the  patient,  may 
be  given.  Water  may  be  allowed  as  desired.  On  the  second  and 
third  days  simply  soups  or  any  of  the  following  may  be  added  to  the 
dietary:  Meat  broths,  beef -tea,  soft-boiled  or  poached  eggs,  raw  or 
stewed  oysters,  and  some  simple  dessert,  such  as  wine-jelly,  boiled 
custard,  or  junket.  During  the  next  few  days  chicken,  scraped  beef 
or  mutton  in  small  quantities,  baked  potato,  rice,  and  cereals  may 
be  given,  and  by  the  end  of  the  week  a  gradual  return  to  the  ordinary 
diet  may  be  made. 

DIET  IN  THE  SPECIAL  DISEASES  OF  PREGNANCY 

Lowered  Urea  Output. — During  pregnancy  the  urine  should  be 
watched  closely,  and  an  examination  for  albumin  be  made  weekly, 
especially  if  there  is  the  slightest  reason  to  suspect  kidney  disease. 
If  albumin  is  found  or  if  any  untoward  symptoms  arise,  the  urea  out- 
put for  twenty-four  hours  should  be  estimated.  If  the  quantity  ex- 
creted is  below  normal,  the  patient  should  be  put  at  once  on  a  milk 
diet,  the  milk  generally  being  skimmed  (see  Milk  Cure  and  Diet  in 
Nephritis).  If  the  patient  tires  of  this,  lettuce  salad  and  bread  and 
butter  may  be  allowed  in  addition,  together  with  zwieback  or  biscuits 
(crackers).  Very  small  quantities  of  herring  roe  may  be  given  as 
a  relish.  An  abundance  of  water,  either  plain  water  or  what  is  known 
as  Buffalo  Lithia  Water,  should  be  drunk.  Cream-of-tartar  lemonade 
(one  dram  to  the  pint)  is  also  useful  as  a  beverage. 

Salivation. — If  this  occurs,  the  patient  should  be  put  upon  a  rigor- 
ous milk  diet. 

Gingivitis. — In  this  condition  a  generous,  well-mixed  diet,  including 
fruit  and  fresh  vegetables,  is  indicated.  In  addition  tonics  and 
astringent  mouth-washes,  especially  those  containing  the  tincture  of 
myrrh,  are  to  be  prescribed. 

Pernicious  Vomiting. — This  is  often  associated  with  diseased  con- 
ditions of  the  kidney.  Whatever  the  cause,  the  patient  should  be 
kept  in  bed  and  placed  upon  a  restricted  diet,  consisting  of  pepton- 
ized milk  and  similar  preparations,  given  in  small  quantities  at  in- 
tervals of  three  or  four  hours,  or  even  oftener.     Rectal  feeding  may 


350  DIET  FOR  SPECIAL  CONDITIONS 

be  employed  for  several  days,  the  patient  being  given  little  or  noth- 
ing by  the  mouth.  High  injections  of  salt  solution  help  to  allay 
thirst  and  to  control  the  condition  itself.  When  the  vomiting  has 
ceased,  the  return  to  an  ordinary  diet  should  be  slowly  and  carefully 
made. 

Aberrant  Mental  Conditions  during  Pregnancy. — The  patient 
should  be  placed  in  bed,  if  possible,  and  excretion  promoted  by  means 
of  baths  and  the  like.  An  exclusive  milk  diet  (or  one  that  is  nearly 
so)  is  generally  to  be  preferred. 

THE  EFFECT  OF  DIET  ON  THE  DEVELOPMENT  AND  STRUCTURE  OF  THE 

UTERUS 

Malcolm  Campbell  ^  has  drawn  the  following  deductions  from  his 
experiments  on  rats:  1.  The  use  of  a  non-physiological  diet — for 
example,  exclusive  flesh,  rice,  or  porridge — induces  in  the  great  ma- 
jority of  cases  a  modification  in  the  structure  of  the  uterine  mucous 
membrane.  This  modification  consists  in  a  diminution  in  the  number 
of  large  connective-tissue  type  of  cells,  which  appear  to  be  important 
constituents  in  a  physiologically  active  mucosa.  2.  The  structural 
change  is  most  profound  in  animals  fed  from  weaning  on  an  exclu- 
sively ox-flesh  diet.  In  such  animals  the  development  of  the  uterus 
is  also  most  interfered  with.  3.  The  structural  change  is  associated 
with  sterility.  Watson  has  pointed  out  that  a  meat  diet,  if  begun  at 
weaning,  almost  invariably  led  to  sterility,  which  is  probably  due  to 
the  structural  developmental  abnormalities  in  the  uterus  induced 
by  the  abnormal  diet.  Campbell  also  calls  attention  to  the  fact  that 
the  consumption  of  meat  per  head  in  England  and  Scotland  is  almost 
seventeen  times  as  great  as  it  was  in  1750.  During  the  same  time 
there  has  been  a  marked  fall  in  the  birth  rate. 

1  British  Medical  Journal,  May  25,  1907,  p.  1229. 


SPECIAL  METHODS  OF  FEEDING 
RECTAL  FEEDING 

Nutrient  Enemata. — The  administration  of  food  by  the  rectum 
is  a  method  of  feeding  of  ancient  origin.  ^Etius  and  others  mention 
it,  and  writers  during-  the  Middle  Ages  have  referred  to  it,  though 
not  in  very  glowing  terms,  their  imperfect  technic  probably  resulting 
in  practical  failure.  Voit  and  Bauer  found  that  a  dog's  rectum 
would  not  absorb  egg-albumin  and  water  unless  sodium  chlorid  were 
mixed  with  it.  This  last  seems  to  cause  reverse  peristalsis,  and 
Griitzner  has  shown  that  substances  introduced  with  the  salt  solution 
may  be  found  in  the  stomach,  a  fact  that  has  been  confirmed  by 
Swieznski. 

Bauer  believes  that  but  one-fourth  of  the  nutriment  needed  by  the 
body  can  be  absorbed  by  the  rectum,  and  both  he  and  the  earlier 
writers  placed  the  limit  of  time  during  which  rectal  feeding  was  prac- 
ticable at  from  one  to  two  weeks.  With  careful  technique,  this  period 
may  be  extended  from  four  to  six  weeks,  depending  on  the  capacity 
of  the  individual  for  continued  absorption,  and  on  the  amount  of 
energy  stored  up  in  his  body  at  the  beginning  of  the  rectal  feeding; 
but  von  Leube  has  kept  a  patient  alive  for  six  months,  and  Riegel  for 
ten  months,  on  exclusively  rectal  feeding.  Some  of  the  more  recent 
writers  have  insisted  strongly  on  the  limits  of  rectal  feeding,  which 
are,  perhaps,  often  misunderstood.  As  only  about  one-fourth,  and 
often  even  less,  of  the  amount  of  nutriment  needed  can  be  absorbed, 
the  method  is  only  useful  in  protecting  the  body  from  excessive  loss 
during  periods  of  partial  or  complete  starvation  due  to  causes 
enumerated  below. 

It  should  be  borne  in  mind  that  the  patient  starts  on  his  period! 
of  rectal  feeding  with  more  strength  than  he  will  have  later  on,  and 
surgeons  and  others  should  not  attempt  to  build  up  a  patient  by  a 
period  of  rectal  feeding.  In  some  protracted  cases  the  metabolic 
processes  evidently  are  carried  on  at  a  very  low  rate,  and  the  small 
amount  of  nourishment  given  by  the  rectum  may  aid  materially  in 
keeping  the  patient  alive,  and  in  other  cases  it  may  bridge  over  a 
critical  period. 

In  starvation  it  is  thought  that  the  amino-acids  in  the  circulation 
from  tissue  destruction  may  be  used  to  build  up  other  tissues  to  some 
extent. 

All  the  various  foods  may  be  utilized  in  rectal  feeding,  but  in- 
vestigators are  not  in  accord  as  to  the  best  forms  nor  as  to  the  amounts 
absorbed  and  the  subject  is  still  worthy  of  further  study.     There  are 

351 


352  SPECIAL  METHODS  OF  FEEDiyO 

probably  wide  individual  variations  so  that  many  careful  abbrevia- 
tions will  have  to  be  made  to  get  at  the  real  facts.  If  von  Leube 
and  Riegel  are  to  be  believed  as  to  the  length  of  time  patients  can 
be  kept  alive  on  milk,  yolk  of  egg  and  wine  mixtures,  then  the  recent 
investigations  may  place  too  low  a  limit  on  the  capabilities  of  the 
bowel  to  absorb  food  administered  in  this  way.  Reverse  peristalsis 
might  explain  some  of  the  exceptions. 

Edsall  places  the  amount  of  nutriment  that  it  is  possible  to  absorb 
by  rectal  feeding  at  about  one-sixth  the  requirements  of  the  body. 
As  far  as  the  protein  is  concerned  it  is  highly  probable  that  some 
thought  to  be  absorbed  as  food  was  destroyed  by  bacterial  action. 

Studies  by  Short  and  Byswater  (British  Medical  Journal  1913,  1, 
1361)  on  the  nitrogen  output  in  the  urine  of  patients  fed  on  milk 
and  egg  mixtures  was  about  that  of  fasting  individuals,  but  those  fed 
on  amino-acids  produced  in  the  laboratory  and  on  milk  pancreatized 
for  twenty-four  hours  showed  better  results.  They  suggest  that  nu- 
trient enemata  should  consist  of  aminoids,  commercially  prepared 
amino-acids.  The  aminoids  made  by  the  Arlington  Chemical  Com- 
pany have  a  value  of  90  calories  per  ounce.  As  far  as  we  know  no 
reports  have  been  published  on  the  use  of  these,  but  they  have  been 
tried  without  any  untoward  effects  and  apparently  with  decided 
benefit.  The  substance  requires  further  investigation.  One  of  the 
French  writers,  Berthelot,  thought  that  untoward  results  were  some- 
times obtained  from  certain  preparations  obtained  by  complete  en- 
zymic  hydrolysis  of  meat  which  he  attributed  to  the  preservatives 
used.  From  a  sample  of  aminoids  there  was  a  total  nitrogen  of 
11.98  per  cent.  Amino  nitrogen  equals  8.90  per  cent.,  or  what  is  a 
little  over  74  per  cent,  of  the  total  nitrogen  in  the  particular  sample. 
From  30  grams  of  this  there  were  3.59  grams  nitrogen ;  74  per  cent, 
of  this  would  yield  2.6  grams  of  amino  acid  nitrogen,  which  theoreti- 
cally should  be  ready  for  blood  absorption.  Aminoids  may  be  ad- 
ministered alone  or  with  dilute  alcohol  solution.  It  should  be  re- 
membered that  this  material,  while  very  promising,  is  still  in  the 
observational  stage.  Pancreatized  milk  (twenty-four  hours)  either 
plain  or  to  which  dextrose  and  alcohol  and  salt  have  been  added,  may 
be  used  and  may  be  alternated  with  the  dextrose  alcohol  mixture 
suggested  for  the  drop  method.  Dextrose  seems  to  be  the  best  car- 
bohydrate for  rectal  feeding. 

There  is  a  great  deal  of  difference  of  opinion  about  the  absorption 
of  fat.  Until  it  has  been  definitely  disproved  that  fats  cannot  be 
utilized  by  this  method  we  suggest  their  use,  perhaps  best  in  the 
form  of  fresh  yolk  of  egg,  one  or  two  of  which  may  be  added  to  the 
above  or  to  plain  twenty-four-hour  pancreatized  milk.  Other  animal 
fats  of  low  melting  point,  as  cod-liver  oil  very  thoroughly  emulsified 
or  better,  homogenized,  might  be  of  service.  The  use  of  fats  requires 
further  observations.     Saponified  fats  have  also  been  suggested. 


RECTAL  FEEDING  353 

As  far  as  we  know  little  has  been  done  in  the  way  of  supplying 
the  mineral  constituents  except  as  they  are  present  in  milk  or  egg 
yolk. 

Alcohol  is  apparently  well  absorbed  in  0.5  to  2  per  cent,  solutions, 
and  is  a  valuable  adjunct  to  nutritive  enemata.  It  would  seem  that 
it  increases  the  absorbability  of  the  other  constituents  of  an  enema. 
Salt  may  be  added  with  advantage  up  to  1  per  cent,  and  seems  to 
aid  in  absorption. 

The  success  of  the  method  depends  largely  on  proper  technie.  With 
poor  technie  the  rectum  soon  becomes  irritable,  and  for  this  reason 
rectal  feeding  should  not  be  intrusted  to  the  nurse  or  the  family,  but 
the  physician  himself  should  see  that  it  is  properly  conducted.  In 
hospitals  or  in  private  practice  where  the  nurse  has  been  specially 
trained  general  directions  may  suffice,  but  in  any  case  explicit  written 
directions  are  advisable.  Once  the  rectum  becomes  irritable  the  proc- 
ess is  conducted  with  difficulty. 

Procedure. — The  rectum  should  be  cleansed  thoroughly  by  ad- 
ministering a  high  injection  of  normal  salt  solution  one  hour  before 
the  enema  is  to  be  given.  This  cleansing  should  be  practised  at  least 
once  a  day,  and  if  much  mucus  is  present,  it  may  be  well  to  precede 
each  feeding  by  a  cleansing  enema.  If  the  rectum  is  inflamed,  a 
solution  of  boric  acid  may  be  used  instead  of  the  salt  solution,  or  if 
there  is  much  mucus,  a  solution  of  sodium  bicarbonate  may  be  em- 
ployed— a  teaspoonful  of  either  to  the  pint  of  water  being  sufficient. 
For  the  first  one  or  two  cleansing  enemata  the  bowel  should  be  flushed 
by  the  ordinary  method ;  later  a  return-flow  catheter  may  be  used ; 
with  this  several  quarts  of  solution  may  be  used ;  without  it  i/o  to  1 
pint  will  be  sufficient  in  most  cases. 

The  temperature  of  the  cleansing  enemata  should  be  between  95° 
and  99°  F. -,  that  of  the  enemata  which  are  to  be  retained,  between 
90°  and  95°  F.  Solutions  that  are  too  hot  or  too  cold  will  promptly 
be  rejected. 

.  The  patient  should  lie  on  his  side,  with  the  hips  well  elevated.  On 
account  of  disease  this  position  may  be  impracticable.  A  rectal  tube 
or  a  large  catheter  should  be  used.  This  should  not,  however,  be  too 
large;  a  tube  1  cm.  (about  half  an  inch  or  less)  being  the  proper  size 
for  an  adult.  For  children  the  tube  should  be  proportionately  smaller. 
It  should  be  lubricated  thoroughly,  but  glycerin  should  not  be  used 
for  this  purpose. 

In  introducing  the  tube,  it  should  be  twisted  slightly,  which  lessens 
the  liability  of  its  becoming  impacted  in  the  rectal  folds.  If  it  is  not 
passed  easily,  a  small  quantity  of  the  fluid  should  be  allowed  to  flow 
in,  which  will  serve  to  balloon  out  the  rectum,  after  which  the  tube 
may  usually  be  passed  with  ease  for  eight  or  ten  inches  or  more.  The 
tube  should  in  all  cases  be  introduced  as  high  up  as  possible,  as  the 
enema  is  thus  more  likely  to  be  retained  and  absorbed.     Theoretically, 

23 


354  SPECIAL  METHODS  OF  FEEDING 

too,  it  is  urged  that  the  blood  from  the  lowest  part  of  the  rectum  is 
returned  through  the  vena  cava,  whereas  that  from  the  higher  parts 
returns  by  way  of  the  portal  system  and  passes  directly  through  the 
liver.  This  is  of  no  practical  moment  here,  as  sugar  solutions  ab- 
sorbed from  the  rectum,  even  when  introduced  into  the  lower  portion, 
do  not  cause  glycosuria.  This  is  explained  by  the  fact  that  the  lower 
portion  of  the  rectum  has  a  small  capacity  and  absorbs  but  little. 

The  fluid  should  be  allowed  to  flow  in  slowly  from  a  funnel  or  a 
fountain -syringe.  In  some  instances,  where  very  small  injections  are 
being  used,  a  small  hard-rubber  syringe  may  be  attached  to  the  tube. 
Care  should  be  taken  to  avoid  injecting  air  with  the  fluid.  The 
method  of  administering  nutrient  enemata  by  means  of  the  old-fash- 
ioned short  hard-rubber  nozzle  of  either  a  piston  or  a  Davidson 
syringe  can  not  be  too  strongly  condemned.  In  the  hands  of  the  un- 
skilful it  may  cause  injury  to  the  rectum,  and  even  if  used  by  a 
trained  nurse,  only  succeeds  in  placing  the  fluid  in  the  lower  part  of 
the  rectum,  where  it  is  apt  to  be  expelled. 

After  the  injection  the  patient  should  lie  as  quietly  as  possible  for 
at  least  an  hour,  and  be  instructed  to  try  to  retain  the  contents  of  the 
bowel.  A  pad  of  gauze  or  a  towel  should  be  pressed  over  the  anus 
for  twenty  minutes  or  half  an  hour,  and  the  mind  should,  if  possible, 
be  diverted  from  the  subject.  After  a  few  days  the  bowel  often 
acquires  a  tolerance  for  the  injections,  and  they  may  be  retained 
without  difficulty. 

If  the  rectum  is  irritable  and  the  fluid  rejected,  it  is  well  to  precede 
the  nutrient  enema  by  a  small  suppository  containing  opium,  or, 
what  is  better,  a  small  rectal  injection  of  the  tincture  of  opium  may 
be  given.  This  may  be  mixed  with  a  little  starch  water,  but  the  whole 
should  be  as  small  as  possible.  The  opium  should  not  be  used  unless 
necessary,  and  the  dose  should  be  just  sufficient  to  quiet  the  bowel ;  or 
the  opium  may  be  added  directly  to  the  enema. 

If  there  are  hemorrhoids,  rectal  feeding  will  be  greatly  interfered 
with.  Before  each  injection  they  may  be  painted  with  a  2  per  cent, 
cocain  solution,  and  between  the  feeding  a  soothing  ointment  should 
be  applied. 

The  amount  to  be  given  at  each  injection  is  an  important  factor. 
As  a  rule,  it  should  not  exceed  14  of  ^  liter,  (I/2  pint).  If  this  is  not 
well  borne,  the  amount  may  be  reduced  to  from  30  to  100  c.c.  (1-3 
oz.). 

The  number  of  enemata  to  be  used  will  depend  somewhat  upon  the 
patient's  constitution;  as  a  general  rule,  five,  or  better  six,  hours 
should  be  allowed  to  elapse  between  each  feeding. 

It  is  well  to  remember  that  packing  in  the  vagina  and  other 
gynecologic  dressings  may  interfere  materially  with  the  injection  of 
fluid  into  the  bowel. 

The  patient's  mouth  should  be  kept  very  clean,  and  the  patient 


RECTAL  FEEDING  355 

may  be  allowed  to  rinse  it  from  time  to  time,  to  help  to  allay  the 
thirst,  which  is  usually  intense.  Under  some  circumstances  water 
may  be  taken  into  the  stomach,  but  where  absolute  rest  of  the  stomach 
is  indicated,  not  even  that  should  be  allowed.  Enemata  of  weak  salt 
solution  may  be  given  to  relieve  thirst,  or  salt  solution  may  be  given 
subcutaneously. 

A  part  of  the  good  eft'ect  of  the  nutrient  enemata  is  the  mental 
satisfaction  following  them,  similar  to  that  following  a  meal.  The 
patient  having  also  the  feeling  that  he  is  not  being  allowed  to  starve. 

Prevention  of  Parotitis  during  Rectal  Feeding. — Fenwick  sug- 
gests that  in  order  to  prevent  the  occurrence  of  parotitis,  it  is  well  to 
promote  continual  secretion  of  saliva  with  the  idea  of  irrigating  the 
ducts  and  so  preventing  an  ascending  infection.  After  experiment- 
ing with  various  things,  upon  which  the  patient  was  directed  to  chew, 
he  settled  on  an  india-rubber  teat  about  2  inches  in  length,  with  the 
result  that  the  mouth  remained  clean  and  moist.  He  has  used  this 
simple  device  in  more  than  300  cases,  and  where  the  gland  was  not 
already  inflamed  at  the  outset  he  had  no  trouble  in  any  of  his  cases. 
Chewing  gum  may  be  used  for  the  same  purpose  with  good  results. 

INDICATIONS  FOR  THE  USE  OF  NUTRIENT  ENEMATA 

Nutrient  enemata  are  indicated: 

1.  In  extremely  weakened  conditions,  as  during  the  progress  of 
fevers,  when  the  quantity  of  food  taken  through  the  mouth  is  insuffi- 
cient to  sustain  life  or  when  even  predigested  food  can  not  be  re- 
tained. 

2.  In  diseases  of  the  pharynx  and  esophagus  in  which  obstructions 
to  the  passage  of  food  exist,  as  from  tumors;  also  occasionally  in 
spasmodic  constrictions  of  the  esophagus  and  in  paralytic  conditions 
of  the  pharynx  when  the  patient  is  unable  to  swallow  food. 

3.  In  diseases  of  the  stomach,  as  in  cancer  occasioning  stricture  of 
the  cardiac  orifice,  with  inability  to  swallow  sufficient  nourishment. 
In  diseases  of  the  stomach  in  which  it  is  important  to  relieve  the 
stomach  of  work — e.  g.,  in  carcinoma,  in  non-malignant  strictures  of 
the  pylorus  with  consequent  dilatation,  and  also  in  ulcer  of  the 
stomach,  both  when  hemorrhage  has  occurred  and  when  liquids  are 
badly  borne.  In  that  form  of  nervous  dyspepsia  known  as  irritable 
stomach,  which  is  accompanied  by  severe  vomiting,  nutrient  enemata 
may  be  given  to  supply  nourishment  to  the  body  when  the  stomach 
can  not  retain  food. 

4.  In  delirious,  comatose,  or  insane  persons  who  can  not  be  fed 
through  the  mouth. 

Nutrient  Enemata  by  the  Drop  Method. — Since  ^lurphy's  intro- 
duction of  continuous  proctoclysis  by  the  drop  method  the  administra- 
tion of  nutrient  enemata  by  the  same  plan  has  been  practised  by 
various  clinicians.     Eberhard  has  recently  called  especial  attention  to 


356  SPECIAL  METHODS  OF  FEEDING 

this  method  of  treatment.  His  apparatus  consists  of  an  ordinary 
quart  can,  inside  of  which  is  placed  another  can  holding  a  pint. 
These  are  connected  by  an  8-inch  pipe,  which  penetrates  the  bottom 
of  each  and  projects  about  2  inches.  A  small  pet-cock  soldered  to 
the  base  of  the  outside  can  allows  water  to  be  withdrawn  at  will. 
Milk  and  egg  or  any  other  nutriment  placed  in  the  smaller  can  is  kept 
warm  and  tiows  freely  on  account  of  its  being  surrounded  by  hot 
water.  Water  at  a  temperature  of  110°  to  115°  F.  seems  to  answer 
all  purposes.  The  remainder  of  the  apparatus  is  the  same  as  used 
for  saline  enteroclysis.  To  insure  ■  absorption  the  bowel  must  be 
cleansed  by  an  enema  each  day.  The  flow  must  be  regulated  to  about 
a  drop  a  second. 

A  fairly  complete  list  of  nutrient  enemata  as  advised  by  the  older 
writers  will  be  found  in  the  first  four  editions  of  this  book,  and  have 
an  historical  interest. 

The  following  formulae  are  suggested : 

1.  Milk,  pancreatized  for  twenty-four  hours  and  boiled,  250  c.c. 
(8  ounces). 

2.  To  the  above  may  be  added  any  of  the  following,  either  alone  or 
in  any  combination: 

1.  Dextrose,  5  to  12.5  grams  (li/4  to  3  drams). 

2.  Alcohol,  5  to  12.5  c.c.  (II/2  to  3  drams). 

3.  Egg  yolk,  1  or  2. 

The  drop  method  is  especially  indicated  in  persistent  vomiting,  in 
hemorrhages,  stenosis  of  the  esophagus  or  pylorus,  in  carcinoma  of 
the  stomach,  and  in  most  conditions  in  which  nutrient  enemata  are 
ordinarily  employed. 

At  present  the  best  mixtures  seem  to  be  normal  salt  solution  to 
which  dextrose  and  alcohol  have  been  added  in  the  proportion  of  .5 
per  cent.  Five  to  20  drops  of  tincture  of  opium  are  advised  by  some 
to  be  added  to  a  liter  during  the  first  day  and  it  is  thought  that  a 
quarter  of  a  grain  of  thymol  per  liter  will  prevent  bacterial  change 
in  the  bowel,  A  liter  of  the  above  contains  550  calories  and  may 
be  administered  in  eight  hours  under  favorable  conditions.  The 
formula  will  be 

Dextrose,  50  grams  (1%  ounces) 

Alcohol,  50  grams  (1%  ounces) 

Normal  salt  solution,  1000  c.c.  (32  ounces) 

This  may  be  found  useful  after  operations,  in  acidosis,  in  diabetic 
coma,  and  in  many  of  the  indications  for  rectal  enemata. 

OTHER  METHODS  OF  NOURISHING  THE  BODY 

Duodenal  Alimentation. — Einhorn,  Morgan,  and  others,  following 
the  suggestion  of  the  first-named  investigator,  have  used  a  duodenal 
tube,  not  only  as  a  matter  of  diagnosis,  but  for  feeding  certain  classes 
of  cases.     At  present  the  tube  has  been  used  in  those  cases  in  which 


OTHER  METHODH  OF  yOLKlSHlXG  THE  BOD)  357 

it  was  thought  desirable  to  rest  the  stomaeh,  as  in  cases  of  persistent 
vomiting  and  in  certain  gastric  and  duodenal  ulcers.  The  ordinary 
Einhorn  tube  is  used,  and  care  should  be  taken  to  see  that  it  is  in 
place  before  the  feeding  is  started.  This  may  be  done  by  gentle  trac- 
tion, which  shows  a  slight  resistance  if  the  tube  is  in  the  duodenum ; 
by  aspiration,  which  will  often  bring  up  golden  yellow  duodenal  juice 
without  any  gastric  secretion ;  or,  perhaps  best,  by  giving  the  patient 
some  liquid  to  drink  by  mouth  and  immediately  performing  aspiration. 
If  the  end  of  the  tube  is  in  the  stomach,  the  fluid  can  be  recovered. 
Any  li([uid  food  may  be  employed,  but  mixtures  of  milk,  sugar,  and 
raw  eggs  are  the  most  useful.  Care  should  be  taken  to  see  that  there 
are  no  particles  in  the  food  that  might  clog  the  tube.  The  amount 
at  the  beginning  should  be  small,  100  c.c.  every  two  hours,  beginning 
early  in  the  mornuig  and  stopping  late  in  the  evening.  This  quan- 
tity, may  be  gradually  increased  up  to  300  c.c.  If  8  feedings  are 
given  in  twenty-four  hours,  and  each  feeding  consists  of  280  c.c.  of 
milk,  1  egg,  and  1  tablespoonful  of  sugar  of  milk,  the  patient  will 
receive  approximately  2280  calories,  which  is  ample  for  an  average 
individual,  and  if  the  patient  is  at  rest  in  bed,  it  is  sufficient  to  allow 
a  gain  in  weight. 

In  some  eases  Einhorn 's  diet  for  duodenal  feeding  consists  of — 

7.30  A.  M. :     Oatmeal   gniel    180  c.c. 

One    egg     

Butter     15  gm. 

l.actose     180  c.c. 

9.30  A.  M. :      Pea  soup    180  c.c. 

One  egg 

Butter    15  gm. 

Lactose         15  gm. 

11.30  A.M.:      Same  as  9.30  a.m. 

1.30  p.  M. :      Bouillon     180  c.c. 

One  egi" 

3.30  P.  M. :     Oatmeal  gruel    180  c.c. 

Butter     15  gm. 

One  egg 

Lactose     15  gm. 

5.30  P.  il. :      Pea  soup    180  c.c. 

Butter    15  gm. 

One  egg 

Lactose     15  gm. 

9.30  P.  M. :      Bouillon     180  c.c. 

One  egg 
Total  quantity : 

Oatmeal  gruel 360  c.c. 

Pea  soup    720  c.c. 

i^ggs   8  c-c- 

Lactose     90  gm. 

Bouillon     360  c.c. 

Butter    90  gm. 

Einhorn  has  perfected  a  special  syringe  with  which  it  is  possible 
to  administer  the  food  without  disconnecting  the  tube.  Morgan  has 
suggested  a  method  like  that  of  ^lurphy  for  giving  salt  solution  per 


358  SPECIAL  METHODS  OF  FEEDING 

rectum,  permitting  the  fluid  to  flow  from  an  irrigating  jar,  and  so 
arranging  the  pet-cock  that  the  food  is  taken  slowly,  the  300  c.c.  of 
nourishment  taking  about  twenty-flve  minutes.  The  food  should  be 
administered  at  bodj'  temperature,  and  the  heating  should  be  done 
slowl}',  as  if  it  becomes  too  hot  it  is  liable  to  become  thick  and  lumpy. 
After  heating  it  is  well  to  strain  the  food  to  be  certain  to  have  it  free 
from  small  particles.  If  the  food  is  used  too  warm  or  too  cold  it  is 
apt  to  cause  uncomfortable  sj'mptoms,  sometimes  causing  the  patient 
considerable  shock :  a  too  rapid  administration  causes  flatulence. 
After  each  feeding  the  syringeful  of  water,  at  98°  F.,  should  be  in- 
jected, then  the  pet-cock  closed,  and  the  syringe  filled  with  air,  which, 
should  be  injected  after  the  pet-cock  has  been  opened:  the  pet-cock 
should  then  be  closed  and  the  syringe  disconnected.  This  procedure 
is  very  important  and  serves  to  keep  the  tube  clean  and  empty.  If 
this  is  not  done,  small  masses  of  food  are  apt  to  be  drawn  into  the 
lower  part  of  the  tube,  and  this  may  necessitate  its  removal. 

Food  suppositories  have  been  suggested,  but  their  use  is  open  to 
many  objections,  the  chief  one,  they  may  not  be  absorbed. 

Nutrient  inunctions,  especially  with  oils,  have  been  suggested,  and 
in  conditions  of  great  emaciation  they  may  prove  useful.  The  body 
is  rubbed  w4th  oil,  such  as  olive  oil,  cod-liver  oil,  or  cocoanut  oil,  or 
with  cocoa-butter.  This  keeps  the  skin  soft,  the  massage  also  proving 
helpful.  It  is  of  particular  value  in  marantic  infants,  and  has  been 
used  as  a  routine  practice  by  the  authors  in  all  such  cases,  with  very 
gratifjnng  results. 

Intravascular  feeding  has  been  tried  out;  for  the  present  it  is 
limited  to  supplying  fluid  in  the  form  of  salt  solution,  alkalis  in  the 
form  of  sodium  bicarbonate  solutions,  or  carbohydrates  in  the  form 
of  glucose  solutions  (See  Acidosis).  The  problem  of  intravenous 
feeding  seems  somewhat  nearer  its  accomplishment,  as  Murlin  and 
Riche,  in  studying  fat  metabolism,  w^ere  able  to  inject  3  per  cent, 
emulsions  of  lard  oil  into  animals  and  it  was  apparently  utilized  and 
two  Danish  observers,  Henriques  and  Anderson,  state  that  they  have 
kept  goats  alive  and  in  nitrogen  equilibrium  by  furnishing  a  slow 
stream  of  nutrients  by  injecting  into  the  jugular  vein  a  mixture  of 
glucose,  sodium  acetate  and  inorganic  salts,  together  with  a  solution 
of  meat  completely  digested  with  pancreatic  trypsin  and  the  intestinal 
enzyme  erepsin.  It  will  doubtless  be  some  time,  however,  before  this 
method  will  be  available  for  human  beings  in  a  safe  and  satisfactory 
form. 

Subcutaneous  feeding  is  a  subject  of  considerable  interest,  and 
was  used  as  early  as  1869  by  Menzel  and  Perko.  Karst,  Kriig, 
Witthaker,  and  others  have  also  employed  this  method.  One  of  the 
most  important  contributions  to  the  subject  has  been  made  by  von 
Leube.  This  observer  could  obtain  no  good  results  from  the  use  of 
either  proteins  or  of  carbohydrates.     He  is  of  the  opinion,  however, 


OTHER  METHODS  OF  XOURISHISG  THE  BODY  359 

that  injections  of  oil  are  of  practical  value  in  nourishing  patients 
under  such  conditions  as  render  it  necessary,  as  in  the  failure  of 
rectal  enemata  because  of  the  presence  of  hemorrhoids  or  irritation 
of  the  rectum.  His  attention  was  directed  to  the  fact  that  large  quan- 
tities of  oil  were  used  in  giving  camphor  injections,  which  are  more 
widely  used  in  Germany  than  in  America.  Fat  emboli  result  so  rarely 
as  to  be  practically  no  objection  to  the  method.  Von  Leube  uses  the 
purest  olive  or  sesame  oil.  and  a  10  c.c.  syringe,  made  after  the  or- 
dinary hypodermatic  syringe  pattern,  or  a  needle,  a  tube,  and  a 
funnel.  From  30  to  40  c.c.  (1-1%  oz.)  of  oil  may  be  used  daily. 
The  contents  of  the  syringe  (10  c.c.)  should  be  injected  in  three  dif- 
ferent places  and  the  wounds  sealed  with  collodion.  The  oil  should 
be  injected  very  slowly,  and.  of  course,  the  strictest  asepsis  must  be 
•observed. 

Lennander.  of  Upsala,  and  various  others  have  suggested  the  use 
of  solutions  of  glucose,  in  varying  strengths,  from  8  to  8  per  cent.,  in 
normal  salt  solution ;  in  some  cases  from  1  to  2  per  cent,  of  alcohol  is 
also  added.  These  solutions  are  used  under  the  skin  or  in  the  rectum, 
and  as  much  as  2  liters  have  been  administered  in  twenty-four  hours, 
giving  a  total  of  160  grams  of  sugar  and  40  grams  of  alcohol.  Kausch 
has  used  this  solution  intravenously,  and  has  recommended  it  particu- 
larly after  operations  on  the  abdomen,  and  especially  in  suppurative 
peritonitis.  From  100  to  200  grams  of  olive  oil  ma}'  be  injected  sub- 
cutaneously  at  the  same  time,  the  whole  affording  a  fair  amount  of 
available  nutritive  material.  Sugar  solutions  have  also  been  used 
locally  in  the  peritoneal  cavity  in  the  treatment  of  suppurative  in- 
flammation. 

Saline  Irrigations  and  Infusions. — 1.  Saline  Rectal  Irrigations. — 
Rectal  saline  injections  are  especially  useful  in  all  conditions  as- 
sociated with  hemorrhage ;  also  in  the  various  infectious  diseases,  as 
well  as  in  intoxications  and  in  those  conditions  in  which  it  is  necessary 
to  allay  thirst. 

The  fluid  used  should  be  a  normal  salt  solution,  and  should  be  given 
high,  with  the  rectal  tube ;  if  it  is  necessary  to  prepare  such  a  solution 
quickly,  a  teaspoonful  of  salt  may  be  added  to  a  pint  of  water,  and 
rapidly  injected  by  means  of  an  ordinarj^  fountain  syringe.  The 
fluid  should  be  at  about  the  temperature  of  the  body,  and  should  be 
administered  slowly,  while  the  patient  is  in  a  reclining  position.  As 
much  as  i^^  to  1  quart  of  the  fluid  can  be  utilized  at  one  time. 

The  Murphy  Method  for  Administering  Solutions  by  Rectum. 
— A  very  useful  method  of  administering  salt  solutions  and  other 
fluids  is  by  the  continuous  proctoclysis  by  the  drop  method  as  sug- 
gested by  Murphy.  This  may  be  used  whenever  it  seems  advisable 
to  increase  the  amount  of  fluid  in  the  system.  It  is  of  particular 
service  when  there  has  been  a  loss  of  blood,  and  also  useful  to  fill 
up  the  system  so  that  further  lymphatic  absorption  is  impossible,  as 


360  SPECIAL  METHODS  OF  FEEDING 

after  operations  about  the  thj-roid.  It  ma}-  also  be  used  wheu  fluids 
cannot  be  taken  by  the  stomach.  Normal  salt  solution  may  be  used  or 
the  solution  advised  by  Murphy,  a  dram  each  of  sodium  chlorid  and 
calcium  chlorid  to  the  pint  of  water.  In  cases  of  great  weakness, 
whisky  or  an  infusion  of  coffee  may  be  added  to  the  salt  solution. 

The  method  of  administering  the  fluid  is  important.  A  fountain 
syringe  or  a  salt  solution  flask,  with  a  rubber  tube  attachment  termi- 
nating in  a  vaginal  hard  rubber  tip,  or  a  catheter,  may  be  used.  After 
the  insertion  of  the  tip  or  catheter  into  the  rectum,  the  flask  is  filled 
with  salt  solution  and  suspended  from  4  to  10  inches  above  the  level 
of  the  rectum  of  the  patient.  The  solution  is  kept  in  a  temperature 
of  100°  F.  by  surrounding  the  flask  with  hot-water  bags.  An  im- 
provement on  this  is  to  use  one  of  the  simple  devices  which  are  on 
the  market  for  regulating  the  drop.  This  may  be  done  by  using  a 
funnel,  and  so  regulating  the  pet-cock  on  the  flask  that  the  fluid 
escapes  a  drop  at  a  time.  The  devices  just  mentioned  are  more  satis- 
factory and  require  less  attention.  Care  and  judgment  should  be 
used  not  to  overload  the  patient  with  water  and  so  overburden  the 
heart. 

Plain  Water  Injections. — In  place  of  using  normal  salt  solution, 
ordinary  water  may  be  used,  as  suggested  by  Lawson,  1908,  and  more 
recently  by  Trout.  The  advantages  of  the  plain  water  are  that  it  is 
absorbed  in  larger  quantities  and  more  rapidly.  Patients  given  salt 
solution  by  rectum  require  nearly  twice  as  much  water  by  mouth  to 
relieve  thirst  as  those  given  plain  water. 

The  patient  does  not  complain  of  tasting  salt,  as  is  often  the  case 
when  salt  solutions  are  used.  In  peritoneal  cases  in  which  there  is 
drainage,  larger  quantities  of  salt  solution  or  plain  water  may  be 
used  than  under  other  circumstances. 

Other  Solutions. — Foods  of  various  kinds,  as  mentioned  above,  may 
be  administered  by  this  method,  and  glucose  solutions,  30  grams  (1 
ounce)  to  the  liter  of  water,  or  normal  salt  solution  may  be  used  to 
advantage,  especially  in  cases  of  threatened  or  developed  acidosis, 
as  in  diabetes  or  following  anesthesia. 

2.  Saline  Infusions, — Saline  infusions  are  given  subcutaneously,  and 
are  especially  useful  in  cases  in  which  rectal  saline  irrigations  can 
not  be  utilized,  as  in  certain  intestinal  diseases  or  when  an  immediate 
effect  is  required,  as  in  sudden  collapse  from  hemorrhage  or  from 
shock.  They  are  also  useful  in  cases  when  large  quantities  of  fluids 
have  been  lost  by  the  body,  as  in  the  diarrheas  of  dysentery  and  of 
cholera,  in  various  infectious  conditions  and  intoxications,  as  in 
pneumonia,  erysipelas,  and  typhoid  fever;  and  in  the  uremia  of 
chronic  Bright 's  disease.  The  most  convenient  location  for  adminis- 
tering the  infusion  is  between  the  chest-wall  and  the  mammary  gland, 
or  deeply  into  some  muscle,  as  in  the  lumbar  region,  abdominal  wall, 
or  buttock.     The  injection  should  be  given  under  the  most  aseptic 


OTHER  METHODS  OF  XOlRlSHiya  THE  BODY  361 

precautions.  No  apparatus  is  required  beyoucl  a  fountain  syringe 
to  which  an  aspirating  needle  is  attached.  The  infusion  should  be 
warm,  and  should  be  allowed  to  run  in  slowly;  frequently  as  much 
as  1  or  2  quarts  can  be  injected  into  one  place.  The  mixture  used 
is  a  normal — 0.6  per  cent. — salt  solution.  In  certain  cases  Gushing  ^ 
prefers  the  following  solution : 

Sodium  c'hlorid   0.900 

Calcium  chlorid    0.026 

Potassium  chloi-id 0.010 

Distilled  water   99,004 

100.000 

Combs  has  reported  a  fatal  case  of  sodium  chlorid  poisoning.  By 
mistake  1  liter  of  saturated  salt  solution  was  ingested  hypodermically. 
When  seen  four  hours  later  she  was  comatose.  After  about  six  hours 
of  coma,  a  period  of  excitation  followed,  she  was  maniacal,  and  talked 
incoherently.  This  condition  persisted  for  twenty-four  hours,  when 
she  died — 124.4  gm.  (1920  gr.)  of  sodium  chlorid  had  been  used. 

1  Cohen's  Physiologic  Therapeutics,  vol.  i.\.,  p.  289. 


DIET  IN  DISEASE 

General  Rules  for  Feeding  the  Sick. — The  nurse  and  family 
should  be  fully  impressed  with  the  importance  of  the  proper  feeding 
of  the  patient.  Definite  directions  as  to  how  much  food,  its  form, 
its  preparation,  and  how  often  it  is  to  be  given,  should  be  written 
out.  In  all  acute  serious  conditions,  as  in  pneumonia  or  in  typhoid 
fever,  a  record  of  these  details  should  be  kept,  together  with  the 
record  of  the  quantity  of  fluid  taken,  the  medicines  given,  etc. 

There  is  usually  a  tendency  to  err  in  either  extreme — that  of  giving 
either  too  much  or  too  little  food.  Care  should  be  taken  that  the 
patient's  wishes  are,  wherever  practicable,  carried  into  effect.  The 
nurse  and  famil}'  should  be  questioned  carefully  as  to  the  patient's 
likes  and  dislikes,  and  also  as  to  his  idiosyncrasies.  A  tactful,  ob- 
serving nurse  is  of  inestimable  value,  but  a  careless  or  stupid  one  is 
an  ever-present  source  of  danger. 

The  training  of  nurses  in  regard  to  feeding  is  often  faulty.  Every 
nurse  should  be  instructed  in  the  subject  of  practical  dietetics,  and 
should  know  how  much  food  is  required  by  the  different  types  of 
patients.  The  details  of  feeding  patients  should  always  be  gone 
into. 

The  food  should  be  given  at  regular  intervals.  In  unconscious  or 
semiconscious  patients  this  is  of  great  importance,  but  it  is  just  as 
important  in  the  conscious,  as  the  appetite  usually  comes  on  at  cer- 
tain times,  and  if  the  meal  is  not  forthcoming,  may  disappear. 

The  appetite  of  the  conscious  patient  and  of  the  convalescent  should 
be  fostered,  and  nothing  done  that  may  in  any  way  disturb  it.  Pa- 
tients vary  much  in  this  particular,  but  as  a  rule  individuals  who 
are  not  overfastidious  when  they  are  well,  become  so  when  weakened 
by  disease. 

The  sick-room  should  be  orderly,  and  no  dishes,  utensils,  or  food 
be  allowed  to  stand  about  the  room  either  before  or  after  using.  All 
food  and  drink  should  be  offered  from  scrupulously  clean  glasses  or 
dishes.  These  should  be  as  dainty  as  possible,  and  the  food  must  be 
made  attractive  in  appearance;  when  the  dish  permits,  it  may  be 
garnished  with  a  sprig  of  green.  The  napkins  and  linen  should  be 
spotless.  The  exterior  surface  of  glasses  and  cups  should  be  wiped 
dry  before  they  are  offered  to  the  patient. 

Food  that  is  stale  or  that  has  acquired  an  unpleasant  taste  from 
standing  in  a  refrigerator  together  with  other  things  should  not  be 
given.  A  strong  egg  in  an  egguog  may  be  the  means  of  turning  a 
patient  forever  against  this  form  of  nourishment.     The  food  should 

362 


DIET  I\  DISEASE  363 

be  tasted  by  the  nurse,  but  never,  when  possible,  in  the  patient's 
presence  or  with  the  same  spoon.  If  there  is  anything  wrong  with 
a  dish,  this  should  be  discovered  and  remedied  before  it  is  brought 
to  the  patient. 

A  nurse  should  always  remember  the  eternal  fitness  of  things. 
Utensils  and  dishes  should  be  used  only  for  the  purpose  for  which 
they  are  intended,  and  not  as  makeshifts  for  other  articles.  After 
caring  for  the  patient  or  removing  evacuations  sufficient  time  should 
be  allowed  to  elapse  before  feeding  is  begun.  The  patient  should  be 
made  to  feel  that  the  utmost  cleanliness  and  care  have  been  observed. 
The  hands  and  face  of  the  patient  should  be  wiped  with  a  moist  cloth 
and  then  dried  before  food  is  given,  and  the  lips  cleansed  after  the 
meal  is  complete. 

The  position  of  the  patient  should  be  as  comfortable  a  one  as  pos- 
sible, and  one  in  which  he  will  not  tire  before  the  meal  is  ended.  If 
the  patient  is  weak,  the  food  should  be  given  in  such  form  that  he 
may  take  enough  of  it  without  inducing  fatigue ;  otherwise  he  may 
become  tired  of  masticating  and  swallowing  and  take  an  insufficient 
amount.  Patients  who  can  sit  up  in  bed  should  be  provided  with  a 
bed-tray  on  which  to  place  the  food.  The  legs  should  be  placed  high 
enough  for  the  patient  to  eat  comfortably  from  it. 

If  the  patient  is  helpless,  care  should  be  exercised  in  giving  food 
so  that  it  will  not  be  drawn  into  the  lungs  during  inspiration  or 
coughing.  This  may  be  avoided  by  giving  the  food  slowly,  and  by 
seeing  that  each  mouthful  is  swallowed  before  another  is  given. 
These  patients  may  be  fed  in  various  ways.  The  food  may  be  given 
from  a  spoon,  or,  what  is  usually  preferred,  from  a  drinking-cup  with 
a  spout,  or  by  using  a  bent  tube  and  allowing  the  patient  to  take  the 
food  from  a  glass.  When  the  patient  is  taking  bread  and  similar 
solids,  great  care  should  be  exercised  not  to  allow  the  crumbs  to  fall 
into  the  bed. 

In  most  severe  illnesses  it  is  necessary  to  awaken  the  patient  during 
the  night  to  administer  food.  This  is  a  point  that  requires  special 
judgment.  Often  the  patient  is  more  in  need  of  sleep  than  of  food. 
If  the  patient  does  not  drop  olf  to  sleep  very  soon  after  taking  food, 
it  may  be  better  to  wait  until  he  awakens  before  giving  it.  As  a 
rule,  however,  in  severe  illness  the  sleep  is  disturbed  for  but  a  few 
minutes  by  taking  food.  A  cup  of  warm  milk  or  similar  light  food 
may  often  induce  sleep. 

The  patient's  mouth  should  always  be  kept  clean.  If  dry  and 
parched,  it  should  be  rinsed  before  and  after  taking  food.  A  suitable 
mouth-wash  is  given  under  the  heading  of  Tuberculosis  (p.  40-4),  but 
any  of  the  alkaline  mouth-washes  may  be  used;  boric  acid  and  water 
also  make  an  efficient  wash.  If  the  mouth  is  dry,  it  should  be 
moistened  from  time  to  time,  and  for  this  purpose  a  little  glycerin, 
water,  and  lemon-juice  will  be  found  useful.     If  the  patient  is  help- 


364  DIET  IN  DISEASE 

less,  the  mouth  may  be  swabbed  out  with  cotton  fastened  to  the  end 
of  a  stout  probe  or  wound  about  the  finger.  This  should  be  moistened 
with  some  antiseptic  solution. 

In  all  cases  where  the  illness  is  likely  to  be  protracted,  arrange- 
ments should  be  made  to  care  for  and  prepare  the  food  with  as  little 
discomfort  to  the  household  as  possible.  For  this  purpose  a  diet 
kitchen  may  be  improvised,  preferably  in  a  room  adjoining  the  pa- 
tient's. If  the  patient's  means  allow,  a  small  sick-room  refrigerator 
should  be  provided,  and  a  tin  receptacle  for  storing  foods  that  do  not 
need  to  be  kept  on  ice.  A  gas  or  alcohol  lamp  will  serve  for  heating 
food,  A  thermometer,  a  graduate,  a  funnel,  and  filter-papers  are 
needed,  and  a  meat-mincing  machine  will  be  found  a  useful  addition. 
Saucepans,  a  dish-pan,  and  a  supply  of  tea  towels  should  also  be 
provided.  Boric  acid  or  borax  and  sodium  bicarbonate  will  help  to 
keep  things  fresh  and  clean.  In  cases  of  infectious  and  communicable 
diseases  a  covered  boiler  for  disinfecting  all  dishes  and  utensils  should 
be  added.  The  dishes  should  be  boiled  in  water  to  which  2  or  3  per 
cent,  of  sodium  bicarbonate  has  been  added,  and  the  boiling  should 
be  allowed  to  continue  for  fully  twenty  minutes  after  the  water  has 
begun  to  boil.  Where  instructions  are  likely  to  be  carelessly  followed 
out,  it  is  best  to  direct  that  the  dishes  be  boiled  for  an  hour. 

Feeding  Unconscious  and  Refractory  Patients. — Unconscious  pa- 
tients may  often  easily  be  fed  by  means  of  a  teaspoon.  Each  spoonful 
should  be  swallowed  before  a  second  is  given,  W,  Oilman  Thompson 
advises  that,  in  the  case  of  comatose  children,  the  nourishment  be 
poured  into  the  nostril  instead  of  into  the  mouth.  The  fluid  thus 
given  is  swallowed,  and  any  excess  returned  by  the  other  nostril.  If 
any  difficulty  is  experienced  in  swallowing,  it  is  best  to  resort  to 
either  the  stomach  or  the  nasal  tube.  With  a  little  practice  most 
patients  can  be  fed  with  the  tube  more  easily  than  in  any  other  way. 
A  mouth-gag  should  be  introduced  or  a  roller  bandage  may  be  placed 
between  the  teeth  and  held  in  place  by  an  assistant.  In  infants  who 
have  no  teeth  this  precaution  is  unnecessary,  as  the  finger  answers 
the  purpose  perfectly.  The  tube,  previously  moistened,  is  passed 
into  the  pharynx  and  rapidly  into  the  stomach.  If  the  tube  is  not 
passed  rapidly  through  the  pharynx,  contraction  may  follow  and 
the  tube  be  prevented  from  entering  the  esophagus.  In  order  to  pass 
the  tube  into  the  esophagus  it  is  necessary  to  hold  it  sufficiently  well 
back  from  the  end. 

If  nasal  feeding  is  to  be  used,  a  nasal  tube,  or  in  case  of  infants 
a  catheter,  is  well  oiled  and  gently  passed  through  the  nose  into  the 
esophagus  and  then  into  the  stomach.  Care  should  be  taken  not  to 
pass  the  tube  into  the  larynx.  This  accident  can  alwaj'S  be  avoided 
by  waiting  a  moment  before  pouring  in  the  food.  Either  stomach  or 
nasal  tube  should  be  provided  with  a  funnel,  and  as  soon  as  the  tube 
has  been  satisfactorily  introduced,  the  nourishment — milk,  milk  and 


FEEDING  I\  I' EVER  365 

egg,  or  whatever  liquid  food  is  desired — may  be  poured  slowly  into  it. 

lu  order  to  prevent  air  from  entering  in  advance  of  the  food  a 
small  quantity  of  the  food  may  be  poured  down  the  side  of  the  funnel 
until  the  tube  is  full.  In  many  eases  it  may  be  desirable  to  wash 
out  the  stomach  before  introducing  the  food.  The  tube  should  be 
withdrawn  rapidly,  so  as  not  to  excite  vomiting.  P^od  so  introduced 
may  be  retained  when  it  would  otherwise  be  vomited.  This  is  true 
both  of  infants  and  adults.  (See  the  sections  on  Gavage,  Forced 
Feeding  in  Tuberculosis,  and  Lavage.) 

In  the  case  of  refractory  patients — the  insane,  the  hj'steric,  and 
others  who  refuse  to  eat — forced  feeding  becomes  necessary.  In  this 
case  enough  attendants  should  be  present  to  control  the  patient.  He 
should  be  held  tirmly  and  the  nasal  or  the  stomach-tube  be  introduced. 
In  order  to  prevent  regurgitation  of  the  food,  which  some  patients 
manage  to  do  quite  skilfully  while  it  is  being  introduced,  the  ribs  may 
be  tickled.  This  prevents  fixation  of  the  diaphragm,  without  which 
the  food  can  not  be  ejected.  This  should  be  done  only  when  occasion 
demands,     (See  Diet  for  the  Insane.) 

FEEDING  IN  FEVER 

Before  directing  attention  to  the  diet  in  special  forms  of  pyrexia 
it  will  be  well  to  consider  brietiy  the  general  dietetic  principles  in- 
volved and  their  application  to  this  class  of  diseases. 

There  existed,  in  former  years,  many  different  views  concerning 
the  correct  method  of  feeding  fever  cases.  Prior  to  the  time  of 
Graves  (1848)  it  was  the  general  practice  to  "starve''  fevers.  Graves 
taught  that  a  fever  patient  required  food  and  should  be  fed,  and  in 
his  lectures,  published  in  1848,  there  appeared  the  much-quoted  sen- 
tence: ''If  you  should  be  in  doubt  as  to  an  epitaph  to  be  placed 
upon  my  grave,  take  this — 'He  fed  fevers/  "  With  the  teaching  of 
Murchison  and  others  this  view  gradually-  replaced  the  older  one,  and 
to-day  the  profession  are  in  accord  regarding  the  diet  indicated  in 
febrile  diseases.  Minor  differences  in  opinion  exist  and  various  theo- 
ries have  been  promulgated,  but  the  practical  application  is  the  same 
in  all  cases. 

In  fever  the  metabolic  processes  are  increased,  while  at  the  same 
time  the  power  of  assimilation  is  lowered.  This  results  in  the  burn- 
ing-up  of  the  body  proteins  as  well  as  of  the  fats.  Indeed,  it  is 
stated  that  the  proteins  suffer  a  greater  loss  proportionately  than  the 
fats.  The  appetite  is  diminished  or  entirely  lost,  there  is  a  marked 
lessened  activity  in  all  the  glands  concerned  in  digestion,  and,  as 
previously  noted,  absorption  and  the  assimilation  of  food  are  much 
below  the  normal.     Thirst  also  is  much  augmented. 

Foods  appropriate  for  healthy  individuals  are  not,  as  a  rule,  suited 
for  fever  patients,  and  solid  foods  usually  cause  vomiting  or  severe 
indigestion.     In  order  properly  to  nourish  a  fever  patient  it  is  neces- 


366  DIET  ly  DISEASE 

sary  that  the  food  be  easy  to  take,  easy  to  digest,  and  easy  to  as- 
similate. Any  food  that  does  not  possess  these  three  qualities  is  not 
suitable  for  a  fever  patient.  When  the  disease  runs  its  course  rapidly, 
the  diet  is  of  no  great  importance,  for  even  if  the  patient  take  but 
little  food,  the  period  of  comparative  fasting  is  a  brief  one  and  any 
loss  is  easily  made  up  while  recovery  is  in  progress.  In  protracted 
diseases,  on  the  other  hand,  such  as  typhoid  fever,  and  in  chronic 
fevers,  the  diet  is  of  primary  importance  and  should  be  the  physician's 
first  care.  In  chronic  diseases  and  in  those  fevers  where  remissions 
occur,  the  periods  when  digestion  is  comparatively  good  should  be 
taken  advantage  of,  and  the  patient  nourished  and  strengthened  as 
much  as  possible. 

In  fevers  the  mouth  requires  especial  care  (see  Typhoid  Fever  and 
Tuberculosis)  ;  the  bowels  likewise  should  be  regulated,  and  constipa- 
tion avoided. 

In  health  the  amount  of  food  is  largely  regulated  by  the  supply 
and  kind  available  and  the  appetite.  In  disease  the  appetite  as  a 
guide  is  apt  to  be  misleading,  and  either  too  little  or  too  much  food 
be  taken.  One  must,  therefore,  be  familiar  with  the  food  require- 
ments of  fever  patients.  For  the  average  man,  weighing  70  kilos 
or  150  pounds,  33  calories  per  kilo  of  body-weight  are  required,  and, 
consequently,  a  total  of  2300  calories  per  day.  These  figures  are 
based  on  the  food  requirements  of  a  healthy  man  at  rest.  At  present 
we  do  not  know  what  the  requirements  of  a  fever  patient  are,  but  it 
appears  that  the  processes  of  metabolism  are  increased,  and  an  in- 
crease of  about  25  per  cent,  should  be  made  to  cover  this.  Approxi- 
mately, 40  calories  per  kilo  may  be  taken  as  a  standard,  and  a  total 
of  some  3000  calories  for  the  individual  of  average  size  (150  pounds). 
If  the  patient  takes  less,  it  will  be  made  up  by  the  destruction  of  his 
body  fat  and  protein,  with  a  consequent  loss  in  weight.  It  must  be 
borne  in  mind  that  the  small  individuals  require  less  and  the  large 
ones  more,  but  the  very  obese  may  be  regarded  as  not  re((uiring  the 
full  amount  for  their  actual  weight,  as  much  of  their  weight  is  made 
up  of  fat,  and  this  probably  does  not  require  the  same  amount  of 
nourishment  as  the  cells  of  the  body  actively  concerned  with  metabol- 
ism. Small  persons  and  younger  individuals  in  the  growing  stages 
require  more  food,  and  the  aged  less.  For  the  young  the  require- 
ments will  be  found  under  the  heading  of  "Age."  Not  only  must 
the  total  quantity  of  food  required  be  considered,  but  the  amount  of 
protein  and  other  food  elements  must  be  taken  into  account.  In 
adults  the  amount  of  protein  required  daily  is  more  or  less  fixed, 
but  the  amount  of  carbohydrate  and  fats  will  vary  with  the  amount 
of  bodily  work  performed.  If  excesses  of  protein  are  given,  it  in- 
volves undue  wear  and  tear  in  katabilizing  and  eliminating  that  above 
the  body's  needs.  Under  ordinary  circumstances  16  grams  of  nitrogen 
daily  are  required,  being  the  practical  equivalent  of  the  118  grams 


FEEDINa  IN  FEVER  367 

of  protein  needed  as  stated  by  Voit.  Chittenden  has  shown  that  even 
under  hard  labor  a  nitrogen  equilibrium  may  be  established  at  even 
less  than  half  that  amount  and  the  individual  continue  in  perfect 
health.  Protein  is  needed  in  the  body  to  repair  the  wear  and  tear, 
and  in  the  young  for  growth.  It  may  also  be  used  for  furnishing 
health  and  energy,  but,  owing  to  what  is  known  as  the  specific 
dynamic  action  of  protein,  perhaps  not  over  about  14  per  cent,  of  the 
total  energy  should  be  supplied  as  protein.  The  reason  for  this  is 
that  in  metabolizing  fat  and  carbohydrates  the  amount  of  heat  pro- 
duced is  slight  and  may  be  disregarded,  but  protein  produces  some 
30  per  cent,  of  its  caloric  value  in  what  might  be  called  "waste  heat," 
as  it  is  not  used  in  the  functions  of  the  body.  It  is  for  this  reason 
that  heat  and  energy  are  not  derived  to  advantage  from  giving  large 
amounts  of  protein,  and  it  explains  why  the  amount  of  protein  food 
is  limited  in  hot  climates,  in  hot  weather,  and  in  fever.  Various 
authorities  place  the  amount  of  protein  needed  by  the  fever  patient 
of  average  size  as  between  65  and  100  grams  a  day.  The  balance 
of  the  number  of  calories  needed  may  be  made  up  of  carbohydrates 
and  fats,  which  it  should  be  remembered  are  burned  up  in  the  body 
completely,  and  are  excreted  as  carbon  dioxide  and  water,  or,  if  not 
completely  oxidized,  are  stored  in  the  body  as  fats.  The  form  in 
which  food  is  to  be  supplied  to  fever  patients  to  meet  the  requirements 
is  a  question  worthy  of  careful  study. 

Milk  is  almost  universally  used  as  a  fever  diet.  It  furnishes  35 
grams  protein  to  the  liter  (roughly  speaking,  to  the  quart)  and  about 
700  calories  (640  to  the  quart).  To  get  the  total  food  requirements 
from  milk  alone,  over  a  gallon  a  day  would  have  to  be  used.  It  is 
better,  therefore,  to  supply  part  of  the  nourishment  by  using  some 
other  food.  Milk  may,  as  a  rule,  be  used  up  to  li/o  to  2  quarts  a 
day,  supplying  some  1200  to  1300  calories  per  day.  But  few  in- 
dividuals can  digest  more  than  this  for  any  length  of  time,  and  even 
this  amount  may  not  be  well  borne  unless  it  be  modified  in  some 
way.  Suggestions  for  modifying  milk  for  adults  may  be  learned  by 
considering  the  methods  used  in  infant  feeding.  The  methods  in 
most  common  use  in  invalid  feeding  are  to  dilute  the  milk  by  adding 
water,  carbonated  water,  Vichy,  lime-water,  or  a  cereal  gruel,  such  as 
barley  or  rice  gruel.  Sodium  citrate  may  sometimes  be  added,  es- 
pecially if  the  curd  gives  rise  to  difficulties  in  digestion,  or  if  milk 
causes  constipation.  From  1  to  5  grains  to  the  ounce  may  be  used. 
Partially  pancreatized  milk  may  be  found  of  especial  value,  and 
buttermilk  and  whole  milk,  which  has  been  inoculated  with  lactic 
acid  bacilli,  are  both  of  service,  particularly  when  there  is  any  dis- 
turbance of  the  intestinal  digestion.  Koumiss,  matzoon,  and  keiir 
may  also  be  used.  Sometimes  it  is  the  taste  of  the  milk  which  is 
ob.iectionable,  and  in  such  cases  the  milk  may  be  flavored  by  the  ad- 
dition of  chocolate,  cocoa,  coffee,  or  some  of  the  numerous  recipes 


368  DIET  ly  DISEASE 

given  in  the  Appendix  of  this  book  may  be  used.  Malted  milk  may 
often  be  used  to  advantage,  and  sometimes  various  invalids'  and 
infants'  foods  may  be  of  value. 

Cream  is  of  great  service,  owing  to  its  high  caloric  value,  and  it 
may  be  added  to  milk  or  be  taken  mixed  with  cereals.  The  remainder 
of  the  protein  may  be  supplied  by  using  eggs,  and  from  four  to  six 
may  be  regarded  as  a  reasonable  number  to  add  to  the  diet.  Eggs 
sometimes  disagree,  but  this  is  more  often  due  to  faulty  methods  of 
preparation  or  to  the  use  of  cold-storage  eggs  than  to  any  real  egg 
idos^'ucrasy.  Eggs  may  be  given  in  numerous  ways — raw,  with 
orange-  or  lemon-juice,  or  with  sherry  or  brandy,  or  merely  with 
pepper  and  salt.  Numerous  egg  and  milk  drinks  can  easily  be  im- 
provised (see  recipes  for  these  and  the  preparation  of  other  foods). 
If  the  patient  can  chew,  there  is  no  objection  to  the  use  of  coddled, 
soft-boiled  or  poached  eggs,  or  a  properly  prepared  omelet. 

Meats  are  ordinarily  not  to  be  used  in  fevers,  although  there  are 
exceptions  to  this  rule.  They  are  objectionable  chiefly  because  their 
use  increases  the  protein  content  of  the  food  above  that  limit  which 
has  been  found  by  clinical  experience  to  be  best  for  fever  patients, 
and  the  products  of  the  metabolism  of  the  extra  amount  of  protein 
add  to  the  work  of  the  already  overburdened  organism,  as  protein 
metabolism  in  the  body  is  increased  already  beyond  the  normal  in 
fever  patients.  Meat  is  objected  to  on  account  of  the  purin  nitrogen 
contained,  and  the  excretion  of  the  end-products  of  these  forms  of 
nitrogen  entails  greater  work  than  a  smaller  amount  of  purin-free 
protein.  The  purin  bodies  are  also  supposed  to  increase  the  tem- 
perature in  fever  patients  if  present  beyond  a  certain  amount.  Meat, 
too,  is  difiScult  of  digestion  unless  well  chewed  or  freely  divided,  and 
many  fever  patients  cannot  properly  masticate  their  food.  If  given 
at  all,  it  should  be  freely  divided.  Meat- juices  are  sometimes  used, 
especially  when  little  or  no  food  is  taken,  but  it  has  but  a  small 
caloric  value.  Bouillon  and  meat  extracts  may  be  occasionally  used, 
but,  as  a  rule,  they  are  best  avoided.  The  commercial  extracts  con- 
tain large  quantities  of  extractives  which  are  undesirable  for  fever 
patients,  and  their  food  value  is  practically  nothing.  Fats  are  to  be 
used  with  caution,  and  chiefly  as  cream  and  butter  and  the  yolk  of 
an  egg.  Excessive  quantities  of  fat  will  cause  indigestion  in  most 
patients,  but  small  amounts  are  generally  well  bonie  if  properly 
administered. 

The  remainder  of  the  dietary  must  be  made  up  of  sugar  and 
starches,  and  these  are  carefully  considered  in  the  article  on  Typhoid 
Fever,  to  which  the  student  is  referred  for  further  details  of  fever 
diet.  Gelatin  preparations  are  often  very  valuable  foods  for  fever 
patients. 

Thirst  is  an  important  symptom  in  fever  patients,  and  one  deserving 
of  considerable  attention.     It  is  to  be  hoped  the  cruel  treatment  of 


FEEDING  IN  FEVER  369 

withholding-  drinks  from  fever  jiatients,  such  as  was  formerly  prac- 
tised, has  disappeared,  never  to  return.  Thirst  is  caused  by  the 
increased  temperature,  the  increased  metabolism,  with  its  coincident 
increase  in  waste-products  to  be  excreted,  aiid  sometimes  apparently 
by  sodium  chlorid  retention. 

If  sufficient  fluid  is  not  supplied,  the  tongue  becomes  coated,  the 
mouth  dry,  the  patient  becomes  more  nervous;  if  there  is  delirium, 
it  may  be  increased,  or,  if  there  is  coma,  it  may  be  deepened.  The 
urine  and  sweat  are  both  diminished.  If  fluid  is  supplied,  the  patient 
will  pass  increased  quantities  of  urine  if  in  cool  air,  or  there  may  be 
sweating,  due  either  to  the  nature  of  the  disease  or  to  the  heat.  In 
some  diseases  thirst  follows  great  abstraction  of  water  from  colliqua- 
tive sweats  or  watery  diarrheal  discharges.  In  cholera  and  infantile 
diarrhea  there  are  cases  in  which  the  blood  actually  becomes  thick, 
owing  to  the  great  abstraction  of  water.  One  of  the  most  important 
indications  for  treatment  in  such  conditions  is  supplying  sufficient 
fluid  by  mouth  or  generally  by  subcutaneous  or  intravenous  infusion. 
Persistent  vomiting  may  cause  similar  conditions,  and  in  young  in- 
fants fever  may  be  induced  by  withholding  fluid,  and  promptly  re- 
lieved by  supplying  it. 

If  the  patient  is  not  getting  sufficient  fluid  with  his  food,  and  he 
generally  is  not,  suitable  beverages  may  be  supplied  at  short  intervals. 
Fluid  should  be  given  whether  the  patient  is  conscious  or  unconscious, 
as  even  conscious  patients  may  really  be  in  mental  states  in  which  they 
will  not  ask  for  even  urgent  necessities.  From  1  to  2  liters  (quarts) 
a  day  may  be  regarded  as  an  average  allowance  for  an  adult  with 
fever.  Further  details  for  giving  fluids  will  be  found  under  the  head- 
ing of  Typhoid  Fever. 

As  a  general  rule,  the  physician  should  see  that  the  patient's  bowels 
are  moved  at  least  once  daily,  and  either  drugs  or  an  enema  may  be 
used,  as  may  be  deemed  best. 

Alcohol. — The  question  as  to  the  value  of  alcohol  in  fevers  is  one 
that  has  been  widely  discussed.  The  safest  view,  probably,  is  that 
which  takes  the  middle  ground,  for  while  alcohol  may  have  been,  and 
still  is,  greatly  abused  in  sickness,  there  can  be  no  doubt  that  it 
renders  great  service,  especially  as  a  food  and  stimulant  in  fevers. 
Since  alcohol  is  not  needed  in  all  cases,  the  growing  tendency  is  to 
restrict  its  use  to  those  cases  in  which  it  is  definitely  indicated.  It 
should  not  be  employed  as  a  routine  measure  in  any  disease,  nor 
should  it  be  used  for  any  length  of  time  where  there  is  a  likelihood 
of  the  patient  acquiring  the  habit.  In  acute  fevers  in  strong  patients, 
where  the  disease  is  apt  to  be  of  short  duration,  it  should  not  be  used. 
If  the  odor  is  apparent  on  the  breath  of  the  patient,  or  if  it  causes 
excitement,  delirium,  or  any  mental  symptoms,  it  should  be  used  only 
in  limited  quantities. 

Alcohol,  it  should  be  remembered,  is  not  only  a  stimulant,  but  a 
24 


370 


DIET  IX  DISEASE 


food  as  well,  each  gram  of  it  furnishing  seven  calories  of  heat  or 
that  equivalent  of  energy  to  the  body.  It  should  not  be  given  too 
early  in  the  disease  lest  its  stimulating  effect  be  lost  as  the  system 
becomes  accustomed  to  it.  On  the  other  hand,  stimulation,  either  by 
alcohol  or  any  other  stimulant,  should  not  be  delayed  too  long.  As 
soon  as  the  pulse  becomes  compressible  and  weak  the  stimvilant  should 
be  administered.  When  one  is  sufficiently  expert  in  auscultation,  the 
need  for  alcohol  can  be  learned  from  the  heart-beat.  When  the  first 
sound  becomes  weak  or  loses  its  sharpness,  it  is  a  sign  that  the  heart 
is  beginning  to  flag.  Sir  Dyce  Duckworth  describes  this  as  follows : 
"The  cardiac  indications  for  the  use  of  alcohol  in  fever  are  a  notable 
loss  of  tone  in  the  first  sound,  especially  if  this  be  inappreciable  at 
the  base  (Stokes'  sign),  and  the  associated  condition  of  the  pulse — 
that  of  low  arterial  pressure  and  the  phase  of  it  known  as  dicrotism." 
In  hyperpyrexia  alcohol  is  of  great  value,  for  when  the  temperature 
runs  very  high  digestion  and  assimilation  are  apt  to  come  almost  to 
a  standstill.  In  these  cases  alcohol  is  easily  absorbed  and  acts  as  a 
stimulant  and  as  a  food.  In  continued  hyperpyrexia  large  amounts 
can  be  given,  and  it  seems  to  be  entirely  used  up  in  the  body  without 
producing  any  mental  symptoms. 

In  the  so-called  asthenic  fevers  alcohol  in  small  amounts  and  at 
quite  frequent  intervals  is  useful.  In  the  very  feeble  and  in  the  aged 
it  may  generally  be  taken  with  great  benefit. 

In  prolonged  fevers  in  children  attended  with  difficulty  in  feeding 
alcohol  is  also  of  value.  In  these  cases  the  heart  indications  are 
usually  well  marked  and  are  reliable  guides  to  the  dosage.  In  giving 
alcohol  to  children  it  should  be  well  diluted,  and  small  frequent 
rather  than  large  doses  at  longer  intervals  should  be  administered. 
Large  doses  are  rarely  needed. 

In  those  habituated  to  the  daily  use  of  alcohol  it  must  be  given  in 
some  form  when  these  persons  become  ill  with  fever  or,  indeed,  when 
confined  to  bed  from  any  cause.  When  alcohol  is  withdrawn  sud- 
denly from  those  accustomed  to  large  daily  amounts  nutrition  rapidly 
fails  and  delirium  not  infrequently  sets  in. 

It  should  be  remembered  that  many  conditions  in  which  alcohol 
was  thought  to  be  indispensable  a  few  years  ago  are  treated  just  as 
satisfactorily  now  without  it. 

The  form  in  which  alcohol  is  to  be  given  fever  patients  depends 
on  individual  taste.  As  a  rule,  pure  whisky  or  brandy  diluted  with 
plain  or  with  a  mineral  water  is  preferable.  If  there  is  a  decided 
preference  for  wines,  a  pure  old  wine,  either  light  or  red,  may  be 
prescribed. 

The  quantity  to  be  given  depends  upon  circumstances,  and  the 
age,  condition,  habits,  and  tolerance  of  the  patient  all  plaj^  an  im- 
portant part  in  deciding  this  question.  In  infants  and  young  chil- 
dren from  1/2  ounce  to  2  ounces  of  whisky  divided  over  twenty-four 


FEEDIXG  JN  FEVER  371 

hours  may  be  regarded  as  a  reasonable  limit.  In  older  children  from 
1  to  4  ounces  in  twenty-four  hours,  and  in  adults  from  4  to  8  ounces 
in  the  same  length  of  time,  form  a  good  average.  In  the  case  of 
habitues  and  also  when  other  circumstances,  too  numerous  to  mention 
here,  warrant,  these  amounts  may  be  increased. 

THE  FEEDING  IN  INEECTIOUS  DISEASES 
DIET  IN  TYPHOID  FEVER 

The  preceding  remarks  on  feeding  fever  patients  in  general  should 
be  carefully  read  before  attempting  to  master  the  diet  for  typhoid- 
fever  patients.  It  should  be  borne  in  mind  that  if  one  understands 
the  diet  in  typhoid  fever  they  are  prepared  to  look  after  the  feeding 
of  almost  any  of  the  febrile  diseases.  It  should  be  remembered  that 
the  management  of  the  diet  in  typhoid  fever  is  one  of  the  most 
important  factors  in  the  treatment  of  the  disease.  The  problem  that 
confronts  the  physician  is  the  feeding  of  a  patient  who  is  to  be  ill 
for  weeks,  who  has  a  diseased  intestine,  and  whose  entire  being  is 
deranged  by  his  malady.  Owing  to  the  fever  and  toxemia  there  is 
a  diminution  in  the  quantity  and  the  quality  of  the  digestive  juices. 
The  muscular  action  of  the  alimentary  tract  is  often  diminished,  the 
liver  is  more  or  less  disturbed,  and  the  bile  less  active  than  normally, 
and  absorption  is  defective. 

It  should  be  borne  in  mind  that  the  mild  case  of  typhoid  needs 
just  as  careful  watching  as  the  severer  one,  as  there  is  the  same 
tendency  to  ulceration  and  hemorrhage.  Indeed,  it  might  almost  be 
said  that  such  complications  are  as  great  in  what  were  at  first  mild 
cases,  owing  to  the  carelessness  with  which  they  are  dieted. 

The  aim  should  be  to  supply  a  sufficient  amount  of  food  to  prevent 
wasting,  and  the  figures  given  in  the  above  consideration  may  be 
taken  as  a  guide.  The  form  in  which  the  food  is  supplied  will  depend 
somewhat  upon  the  patient,  his  surroundings,  and  the  ability  to  supply 
foods ;  but  in  a  general  way  this  ofi'ers  but  little  difficulty.  At  times 
the  ingenuity  of  doctor  and  nurse  will  be  called  upon.  The  food 
should  be  adapted  to  the  patient's  digestive  powers  and,  if  he  is  not 
apathetic,  as  far  as  possible,  to  his  tastes.  While  the  old  days  of 
starvation  have  fortunately  passed  away,  we  are  now  swinging  to  the 
other  extreme,  and  care  should  be  taken  not  to  overfeed  the  patient 
in  the  endeavor  to  meet  his  real  or  supposed  caloric  needs.  ^Minor 
digestive  difficulties  should  be  watched  for  and,  if  possible,  corrected. 
Any  food  which  causes  tympany  should  be  avoided,  as  the  distention 
of  the  intestines  with  gas  is  one  of  the  great  factors  in  causing  hemor- 
rhage. The  ulcers  may  be  put  on  a  stretch  and  the  weakened  walls 
of  the  swollen  vessels  may  be  ruptured,  and,  what  is  most  serious, 
only  partially  ruptured,  so  that  the  vessel  is  deprived  of  the  normal 
power  to  control  and  stop  the  bleeding.     It  may  be  made  a  rule  that 


372  DIET  IX  DISEASE 

any  food  which  produces  gas  should  be  avoided;  bat  remember  that 
what  causes  gas  in  one  patient  may  not  in  another,  that  this  gas 
formation  may  be  due  to  other  factors  than  food,  and  that  a  food 
that  at  one  time  disagrees  may  later  on  again  be  of  service.  Thus, 
gas  may  be  caused  by  the  digestion  being  lessened  through  reflex 
action,  as  by  a  too  long  cold  bath,  or  a  visit  from  a  too  talkative 
friend,  and  in  numerous  ways,  which  must  be  carefully  considered 
before  eliminating  valuable  food  from  the  dietary. 

How  much  at  a  time  and  how  often  should  food  be  administered 
is  an  important  question.  The  best  way  to  answer  this  is  to  figure 
on  the  total  quantity  of  food,  and  then  ascertain  how  much  must  be 
given  at  a  time  to  get  in  the  entire  amount  in  twenty-four  hours. 
Thus,  if  48  ounces  are  given,  if  the  feeding  interval  is  three  hours, 
7  or  8  feedings  could  be  counted  on  in  the  day  and  night  together, 
and  6  or  7  ounces  of  food  should  be  given  at  a  time,  the  latter  pre- 
ferably, as  it  will  then  allow  a  longer  sleeping  period  or  periods  at 
night.  If  the  food  is  well  borne  and  only  6  or  even  5  feedings  given, 
the  amount  must  be  larger — 8  ounces  or  9  or  10  ounces  being  given 
at  a  time.  Where  the  total  is  greater,  the  feedings  must  be  larger. 
When  the  food  is  taken  with  difficulty  and  poorly  retained,  feeding 
at  two-hour  intervals  may  be  used,  and  3-  or  4-ounce  feedings  given, 
or  5  or  6  ounces  if  the  food  has  been  diluted.  This  question  of  in- 
tervals and  quantities  must  be  studied  for  each  individual  patient, 
and  varied  according  to  the  necessities  of  the  case.  It  should  be 
remembered  that  where  the  food  is  diluted,  either  on  account  of  the 
digestion  of  the  patient  or  with  the  idea  of  the  patient's  taking  more 
water  with  the  food,  as  when  it  is  thought  desirable  to  disturb  him 
as  little  as  possible,  the  quantity  given  may,  as  a  rule,  be  greater 
than  it  would  with  the  more  concentrated  foods.  When  the  patient 
takes  his  food  poorly  and  is  apathetic,  drowsy,  or  comatose,  the  night 
and  day  intervals  may  be  made  the  same.  If  the  patient  takes  his 
food  fairly  well  and  sleeps  poorly,  or  has  difficulty  in  getting  to  sleep 
if  disturbed,  then  the  day  intervals  may  be  shortened  and  the  night 
intervals  lengthened. 

The  question  of  supplying  fluid  is  an  important  one.  Many  pa- 
tients suffer  for  want  of  water,  and  cannot  or  do  not  express  their 
desire  for  it.  If  the  tongue  is  dry  and  crusted  and  the  mouth  and 
lips  covered  with  sores,  the  patient  needs  more  care  and  more  water, 
and  especially  water  and  acid.  Going  to  the  extreme.  Gushing  and 
Glarke  have  suggested  as  much  as  a  gallon  or  more  water  in  twentj'- 
four  hours,  giving  it  in  small  definite  quantities  at  short  intervals. 
Gopious  elimination  of  urine  follows,  corresponding  to  the  amount 
of  water  ingested.  They  claim  that  the  patient  is  more  comfortable 
and  that  he  is  less  toxic,  and  that  the  nervous  symptoms  are  less  when 
large  quantities  of  water  are  given.  This  may  be  partly  due  to  the 
elimination  of  the  sodium  chlorid,  which  may  be  retained  in  larger 


THE  FEEDIMJ  IX  IXFECTlOiS  Dh^EAtSElS  373 

quantities  than  normal  in  typhoid.  Such  retention  is  not  apt  to  be 
the  ease  in  a  milk  diet,  and  the  objection  offered  that  so  much  fluid 
eliminates  too  many  of  the  body  salts  is  worthy  of  consideration. 
The  work  of  pumping  the  increased  amount  of  fluid  is  another  point 
to  be  considered,  especialh'  in  patients  with  weak  hearts.  This  ques- 
tion is  one  for  further  study.  Three  or  four  pints  of  water  a  day, 
in  addition  to  that  taken  with  the  food,  may  ordinarily  be  regarded 
as  a  fair  allowance. 

Plain  water  is  usually  the  best,  but  there  may  be  reasoiis  for  chang- 
ing the  drink  of  the  patient.  Some  patients  tire  of  plain  water  and 
like  a  change;  sometimes  stimulants,  foods,  or  acids  may  be  thought 
desirable.  Carbonated  waters  may  be  given  if  desired.  The  natural 
ones  are  to  be  preferred  to  those  artificially  charged,  and  the  excessive 
amounts  of  gas  may  be  allowed  to  escape  by  effervescence  before  they 
are  given.  Sometimes  when  the  stomach  is  irritable  the  carbonated 
waters  act  as  a  sedative.  The  commonest  need  is  for  an  acid,  and 
water  acidulated  with  diluted  phosphate  or  by  hydrochloric  acid  is 
of  great  service.  When  there  is  diarrhea,  small  doses  of  aromatic 
sulphuric  acid  may  be  given  in  this  way  to  great  advantage.  Weak 
tea,  with  or  without  the  addition  of  a  little  red  wine,  is  a  great  thirst 
quencher,  but  acts  somewhat  as  an  astringent.  Fruit-juice  and  water 
are  pleasant  when  there  is  no  intestinal  disturbance,  and  are  also  of 
value  if  there  is  constipation.  Lemonade,  orangeade,  grapefruit  juice 
and  water,  grape  juice,  raspberry  juice,  raspberry  vinegar,  all  diluted 
with  water,  are  most  commonly  used.  These  may  be  utilized  as 
vehicles  for  administering  sugar  where  desired,  xllcoholic  beverages 
may  be  given  if  thought  desirable.  Red  or  white  wines  with  water, 
or  even  sherry  or  brandy  and  water,  may  be  relished  by  some  patients. 
French  or  Italian  vermouth,  well  diluted  with  a  carbonated  water, 
is  often  taken  to  advantage.  Under  ordinary  circumstances  old 
whisky,  properly  diluted,  may  be  the  best  alcoholic  drink;  in  some 
patients  it  exerts  a  slight  laxative  effect;  brandy  is  useful  if  there  is 
diarrhea,  and  gin  may  occasionally  be  given  for  its  diuretic  effect. 
It  may  be  made  into  a  pleasant  drink  with  lime  or  lemon  juice  and  a 
carbonated  water. 

Coffee  is  an  excellent  cardiac  stimulant  and  diuretic,  and  may  be 
of  great  service.  It  does  not  always  agree,  and  it  sometimes  causes 
great  wakefulness;  but  the  previous  experience  of  the  patient  with 
coffee  is  usually  a  good  guide.  Of  the  combinations  of  food  and 
drinks — aside  from  milk — there  are  a  great  many,  among  which  may 
be  mentioned  albumin-water,  barley-,  rice-  and  oatmeal-water,  arrow- 
root-water, toast-water,  gum-arabic-water,  and  the  like. 

Coleman  and  DuBois  have  determined  that  foods  are  oxidized  in 
typhoid  approximately  as  in  health,  but  that  the  specific  dynamic 
action  of  protein  and  carbohydrate  is  less  than  in  health,  but  it  may 
be  increased  during  convalescence.     Typhoid  patients  can  store  body 


374  DIET  IN  DISEASE 

fat  on  an  abundant  diet  while  losing  body  weight  and  protein.  The 
loss  in  weight  and  the  loss  in  protein  are  usually,  though  not  neces- 
sarily, parallel.  Patients  may  have  a  negative  nitrogen  balance  on 
diets  containing  more  than  enough  to  cover  their  bodies'  needs. 

How  much  food  does  the  patient  with  typhoid  need  is  a  question 
still  under  discussion.  The  requirements  generally  agreed  upon  con- 
sist of  some  40  calories  per  kilogram  of  body-weight,  or  about  3000 
calories  a  day  for  a  patient  weighing  150  pounds.  Shaffer  and  Cole- 
man found  that  on  a  mixed  diet  a  nitrogen  equilibrium  could  not  be 
established  on  this  amount.  When  the  amounts  were  increased  to 
60  to  80  calories  per  kilogram  of  body-weight,  or  a  total  of  4000  to 
5500  calories,  the  nitrogen  equilibrium  was  established.  There  were, 
however,  wide  variations  at  different  times,  even  in  the  same  indi- 
viduals. On  the  other  hand,  Grafe,  studying  the  metabolism  in 
typhoid  patients  who  were  fasting,  only  once  reached  40  calories  per 
kilo.  Further  studies  will  be  necessary  to  explain  these  various 
points,  and  in  the  meantime  the  food  amounts  that  are  best  for  typhoid 
patients  will  have  to  be  determined  clinically.  The  truth  will  be 
found  ill  the  fact  that  food  requirements  vary  with  the  individual 
and  the  character  of  the  disease.  Nothing  will  replace  the  study  of 
the  individual  case.  In  former  days  there  can  be  no  question  that 
fever  patients,  and  especially  typhoid  patients,  were  starved,  but  it 
is  just  as  important  not  to  overfeed.  The  individual  requirements 
of  a  patient — especially  in  private  practice — is  a  vague  thing  to  many 
physicians,  and  a  word  or  two  may  not  be  out  of  place.  The  general 
appearance  means  much.  If  the  patient  looks  more  or  less  well,  it 
is  a  favorable  sign.  If  he  is  anxious  or  irritable,  it  may  be  on  ac- 
count of  too  little  or  too  nnich  food,  or  due  to  gastric  or  intestinal 
distress,  or,  of  course,  it  may  be  due  to  many  other  conditions.  Ex- 
perience or  judgment  are  needed  to  decide  what  is  wrong.  The 
weight  of  the  patient  is  the  best  guide  to  the  state  of  his  nutrition. 
In  many  hospitals  appliances  are  to  be  found  for  weighing  patients 
in  bed,  and  where  these  are  not  at  hand  the  eye  must  be  trained  to 
see  and  the  hand  to  feel  the  condition  of  the  tissues,  and  one  soon 
learns  to  appreciate  whether  the  patient  is  gaining  or  losing.  If  he 
is  losing,  it  is  a  good  general  rule  to  try  and  give  more  food,  if  there 
be  no  contraindications  to  this,  and  there  generally  are  not.  The 
appetite  is  important,  and  if  the  patient  is  hungry,  it  is  a  good  plan 
to  try  to  give  sufficient  food  to  make  the  patient  comfortable.  If  the 
mouth  is  coated  and  dry,  fluid  and  acids  should  be  given.  If  the 
tongue  and  mucous  membranes  are  bright  red  or  scarlet,  alkalis,  such 
as  Vichy,  should  be  administered.  This  is  rarely  the  case  in  typhoid. 
If  the  patient  is  toxic,  more  fluid  should  be  tried,  and  this  may  also 
be  tried  in  restless  and  irritable  patients. 

The  ratio  of  protein,  fat,  and  carbohydrate  on  which  the  patient 
does  best  cannot  be  definitely  stated  at  this  time,  and  doubtless  varies 


TEE  FEEDIXa  IS  INFECTIOUS  DISEASES  375 

both  in  the  patient  and  the  stage  and  the  character  of  the  disease. 
From  60  to  95  gm.  of  protein  a  day  have  given  the  best  results  in 
cases  in  which  metabolism  studies  have  been  made.  Purin  nitrogen 
seems  to  be  more  apt  to  raise  the  temperature,  hence  foods  containing 
purin  nitrogen  should  be  sparingly  used  during  the  febrile  period. 
These  foods  are  discussed  under  the  head  of  Gout.  The  principal 
foods  containing  purin  nitrogen  are  meats,  tish,  peas,  beans,  asparagus, 
onions,  mushrooms,  and  oatmeal.  A  purin-free  diet  need  not  be 
considered  here,  but  may  be  borne  in  mind. 

The  possibility  of  feeding  fats  varies,  but  Coleman  found  that 
they  were  better  borne  when  the  temperature  began  making  wide 
remissions  and  during  convalescence.  Cream  and  butter  have  been 
used  in  considerable  quantities,  and  with  apparent  benefit.  Carbo- 
hydrates have  been  found  to  be  of  especial  value  in  supplying  the 
needs  of  typhoid  patients,  and  it  would  seem  that  9.  very  considerable 
amount  of  the  daily  food  may  consist  of  carbohj'drates,  especially  so 
when  high  caloric  diets  are  used. 

We  now  come  to  the  choice  of  foods  and  the  actual  amounts  that 
may  usually  be  given.  Milk  has  always  been,  and  doubtless  will 
always  continue  to  be,  a  favorite  food  in  typhoid  fever.  This  topic 
has  often  been  the  subject  of  debates.  Suffice  it  to  say  that  practical 
experience  demonstrates  that  milk  may  be  taken  in  large  quantities, 
and  generally  to  advantage.  Bear  in  mind  that  a  satisfactory  typhoid 
diet  may  easily  be  arranged  without  milk,  should  it  be  thought  de- 
sirable to  do  so.  Some  patients  cannot  take  milk  without  gastric  or 
intestinal  disturbance,  but  those  people  in  whom  actual  milk  idio- 
syncrasy exists  are  the  exception.  IMilk  generally  agrees  if  properly 
modified.  It  may  cause  tympanites,  it  may  cause  diarrhea,  and  some- 
times it  may  cause  gastric  indigestion.  When  any  of  these  occur,  it 
should  be  omitted  from  the  diet  for  a  day  or  two,  and  then  started 
again,  using  some  different  modification.  The  methods  of  modifying 
milk  in  the  diets  for  fevers  have  been  fully  discussed  above.  The 
quantities  used  in  typhoid  may  be  put  down  at  from  ly^  to  2  liters 
(quarts)  in  twenty-four  hours.  To  this  may  be  added  250  c.c.  (I/2 
pint)  of  20  per  cent.,  or  16  per  cent,  cream,  should  it  be  desired  to 
increase  the  calories  by  using  milk.  Sometimes  as  much  as  3  liters 
(quarts)  of  milk  may  be  used,  but  there  are  not  many  patients  who 
can  digest  that  amount  for  any  length  of  time.  Children  are  more 
apt  to  take  milk  over  long  periods  of  time  without  untoward  effects 
than  adults.  We  have  used  milk  verj^  largely  at  the  Robert  Garrett 
Hospital  for  Children,  in  Baltimore,  and  it  agrees  admirably  in  most 
cases.  For  years  we  used  it  almost  exclusively,  but  in  recent  years 
we  have  been  inclined  to  a  more  liberal  dietary.  Kerley  believes  that 
the  milk  diet  used  in  children  is  largely  responsible  for  the  compara- 
tively high  mortality,  but  we  cannot  agree  with  him.  Bad  results 
may  be  noted  at  times,  but  they  are  usually  the  result  of  unskilful 


376  DIET  ly  DISEASE 

feeding,  and  not  to  the  milk  itself.  High  calorie  diets  are,  as  a  rule, 
not  well  borne  by  the  very  young. 

Eggs  may  be  used  in  tj^phoid  fever  to  advantage.  We  formerly 
taught  that  eggs  were  not  well  borne,  but  this  statement  applies  only 
to  cold-storage  eggs.  Only  fresh  eggs  should  be  used.  Eggs  may  be 
given  as  albumin-water,  or  the  whole  raw  egg  may  be  shaken  up  with 
milk,  or  with  other  articles  of  food,  into  palatable  drinks.  Coddled 
eggs,  soft-boiled  eggs,  or  poached  eggs  may  also  be  used  if  the  patient 
is  sufficiently  well  to  masticate  them.  From  four  to  six  eggs  may  be 
given  daily.  Meats  are  not  suitable  for  typhoid  patients.  They  con- 
tain too  much  nitrogen,  and  this  in  itself  is  liable  to  upset  the  metabo- 
lism. Meat  is  objectionable  on  account  of  its  so-called  dynamic 
action,  and  also  because  of  the  purin  nitrogen  which  it  contains. 
Beef-juice  may  be  given  in  exceptional  cases,  and  bouillon  or  beef 
extracts  may  be  used  as  appetizers,  but  they  contain  too  little  nutri- 
ment to  be  of  any  value.  During  convalescence  meats  are  of  great 
value,  and  fat  may  be  given  as  the  yolk  of  eggs,  six  yolks  a  day  being 
the  maximum  average.  Cream  may  be  used  to  advantage^  and  butter 
may  also  be  given.  Too  high  fat  always  causes  trouble,  and  its  use 
should  be  carefully  watched. 

The  carbohydrates  allowable  consist  of  the  various  sugars  and 
starches.  Of  the  sugars,  cane-sugar  and  milk-sugar  may  be  used  to 
greater  advantage  than  any  of  the  others.  Cane-sugar  is  so  sweet 
that  scarcely  more  than  a  tablespoonful  can  be  added  to  6  or  8  ounces 
of  milk,  lemonade,  coffee,  and  similar  drinks.  Milk-sugar  is  not  so 
sweet,  and  is  well  borne,  as  a  rule.  In  children  with  diarrhea  it 
should  be  used  cautiously,  if  at  all.  Several  tablespoonfuls  may  be 
given  at  a  time  if  desired.  It  should  be  given  in  lemonade  or  coffee 
or  in  milk,  as  suggested  below.  Starches  are  best  given  as  cereal 
gruels,  toast,  zwieback,  and  crackers.  Starchy  foods  for  typhoid 
patients  should  contain  little  or  no  cellulose,  and  should  be  as  free 
from  water  as  possible.  They  should  always  be  well  cooked  and 
prepared,  so  as  to  be  palatable  and  easy  of  digestion.  Starches  are 
bulky  foods  at  best. 

Malted  milk  is  a  valuable  food  in  some  cases,  especially  in  difficult 
ones,  and  particularly  so  in  children  who  take  milk  and  other  foods 
poorly.  The  proprietary  foods,  consisting  of  beef  and  alcohol,  should 
not  be  used  except  now  and  then  when  everything  seems  to  disagree 
or  pall. 

Alcohol  may  be  used  according  to  the  rules  laid  down  for  fevers 
in  general. 

The  following  suggestions  as  to  caloric  values  will  be  found  of  value 
in  arranging  dietaries.     The  figures  are  approximate : 

Milk,  1  liter  (quart)    n.in.O 

Milk,  30  gm.   ( 1  ounce )    20.0 

Cream.  2()  per  cent..  500  c.c.   ( 1  pint)    1000.0 


TEE  FEEDl^U  IN  INFECTIOUS  DISEASES  377 

Whey,  30  gm.    (  1  ounce)    10.0 

Buttermilk,  30  gni.    ( 1  ounce) 10.0 

Condensed  milk,  30  gm.  (1  ounce) 132.0 

Whole  egg 80.0 

White  of  egg    30.0 

Yolk  of  egg 50.0 

Cane-sugar,  30  gm.   (  1  ounce)    .  .                        .  1 16.0 

Milk-sugar.  30  gm    (  1  ounce  by  weight) 110.0 

Milk-sugar,  20  gm.   (1  ounce  by  volume)    72  0 

^lilk-sugar,  !t  gm     ( 1  tablespoonful)    .  36.0 

Barley  Hour.  30  gm     (1  ounce  by  weight)      100  0 

Rice  hour,  30  gm    ( 1  ounce  by  weight)      100.0 

Boiled  rice,  1  tablespoonful   60  0 

Toast,  average  slice .  .  SO.O 

Toast,   thick   slice    100.0 

Bread,  average  slice 80.0 

Bread,  thick  slice 100  0 

Crackers,  1  ounce 114.0 

Applesauce,  30  gm.   ( 1  ounce)    30.0 

Further  suggestions  will  be  found  in  Roberts'  tables  of  the  caloric 
value  of  household  measures  of  foods  (p.  91),  and  in  the  table  of 
caloric  values  of  common  foods  per  ounce  (p.  92). 

Irving  Fisher  has  suggested  that  the  labor  of  computing  diets  can 
be  much  simplified  by  serving  foods  in  standard  portions  of  100 
calories  each,  and  his  table,  showing  the  amounts,  together  with  the 
number  of  calories  furnished  by  protein,  fats,  and  carbohydrates,  will 
be  found  elsewhere  in  this  volume. 

In  making  up  the  dietary  for  the  typhoid  patient  the  following 
foods  should  be  borne  in  mind,  while  additional  ones  will  suggest 
themselves  by  looking  over  the  recipes  at  the  end  of  the  book : 

Milk.  Kumiss. 

Cream  Cocoa. 

Buttermilk.  Chocolate. 

Whey.  Ice  cream. 

Junket.  Malted  milk 
Matzoon. 

Soups. — Beef,  veal,  chicken,  tomato,  potato,  etc.  These  may  be 
thickened  with  rice,  barley,  arrowroot,  wheat  flour,  or  with  egg  or 
milk.     Well-boiled  rice,  sago,  or  barley-  may  also  be  used. 

Eaw    eggs.  Stokes'  brandy-and-egg  mixture. 

Yolk  of  egg.  Egg-nog. 

Custards.  Milk-toast 

Egg   and   milk.  Crackers  and  milk. 

Well-cooked  cereals,  such  as  rice,  barley,  cream  of  wheat,  sago, 
arrowroot,  cornmeal. 

Soft  puddings. 

Blanc  mange. 

Cornstarch  pudding  and  similar  preparations. 

Thoroughly  cooked  macaroni  or  spaghetti. 

Apple-sauce,  lemonade,  orangeade. 

Gelatin  jellies. 


378  DIET  IN  DISEASE 

Scraped  meat,  raw  or  boiled,  given  with  care  and  only  in  small 
amounts. 

Oatmeal  is  ordinarily  not  suited  as  a  food  for  typhoid  fever  pa- 
tients, but  sometimes  is  used.  It  should  be  cooked  live  hours  and 
strained. 

Pea-soup  and  bean-soup  have  been  suggested,  but  ordinarily  are 
objectionable  on  two  grounds — the  purin  nitrogen  contained  and  their 
great  tendency  to  cause  flatulence  in  some  patients. 

Baked  or  mashed  potatoes  may  be  used  sparingly. 

High  Caloric  D/ef.— Shattuck,  of  Boston,  has  long  advocated  more 
liberal  feeding  in  typhoid  patients,  and  Coleman  and  Shaffer  have 
experimented  with  it  extensively.  The  following  is  largely  taken 
from  Coleman's  article  in  the  American  Journal  of  the  Medical 
Sciences  for  January,  1912:  We  have  gone  into  the  subject  in  con- 
siderable detail,  as  it  shows  what  can  be  done  practically  in  high  cal- 
oric feeding,  and  a  careful  study  of  the  method  teaches  many  lessons 
in  fever  feeding.  If  the  patient  is  sufficiently  well  to  take  notice,  he 
can  be  told  that  the  more  he  eats  the  better,  and  that  he  may  ask  for 
articles  of  diet  which  may  be  allowed  if  they  are  suitable.  The  large 
quantities  of  milk-sugar  suggested  are  often  well  taken  in  one  food 
and  objected  to  in  another.  During  the  first  few  days  of  observation 
milk  may  be  used  and  then  the  diet  gradually  increased.  During  the 
early  stage  3000  calories  may  be  about  all  the  patient  will  take ;  later, 
the  amount  may  be  increased  to  4000  or  6000  calories.  If  the  patient 
has  any  great  amount  of  discomfort  or  shows  symptoms  of  indigestion 
or  of  malassimilation  of  the  food,  the  amount  should  be  decreased 
at  once.  Any  form  of  food  that  disagrees  should  be  discontinued, 
lest  the  disturbance  so  caused  should  interfere  seriously  with  the 
future  feeding  of  the  patient. 

Coleman's  Milk,  Cream,  and  Lactose  Diets. 

For   1000  calories  a  dav:  Calories. 

Milk,  1  quart   (  1000  c.c. )    .    .  700 

Cream  Ig  ounces    ( 50  c.c. )    100 

Lactose,  1  §  ounces  i  50  gm. )    200 

This  furnishes  eight  feedings,  each  containing: 

Milk,  4  ounces    80 

Cream,  2  drams 15 

Lactose,  6  grams 24 

For  1500  calories  a  dav: 

Milk,  1 J  quarts   ( 1500  c.c. )    1000 

Cream,  If  ounces   100 

Lactose,  3J  ounces  ( 100  gm. )    400 

This  furnishes  six  feedings,  each  containing: 

Milk,  8  ounces 160 

Cream,  2  drams 15 

Lactose,  16  grams  64  • 

For  2000  calories  a  dav: 

Milk,  U  quarts   .  .* 1000 


THE  FEEDING  IN  INFECTIOUS  DISEASES 


379 


Cream,  8  ounces  ( 240  c.c. )    500 

Lactose,  4  ounces   ( 125  gm. )    500 

This  furnishes  seven  feedings,  each  containing: 

Milk,  7  ounces 140 

Cream,   1  ounce   60 

Lactose,  18  grams 72 

For  2500  calories  a  day : 

]\Iilk,  U  quarts     * 1000 

Cream,  8  ounces   500 

Lactose,  8  ounces   (250  gm.)    1000 

Tliis  furnishes  seven  feedings,  each  containing: 

Milk,  7  ounces 140 

Ci'eam,  1  ounce 60 

Lactose,  36  grams    144 

For  3000  calories  a  day: 

Milk,  n  quarts   1000 

Cream,   1   pint    (480  c.c.) 1000 

Lactose,  8  ounces   1000 

This  furnishes  eight  feedings,  each  containing: 

Milk,   6  ounces 120 

Cream,  2  ounces   120 

Lactose,  1  ounce   ( 30  gm. )    120 

For  3900  calories  a  dav: 

Milk,  U  quarts   .  .' 1000 

Cream,   1  pint    1000 

Lactose.  16  ounces   (480  gm.)    1900 

This  furnishes  eiaht  feedings,  each  containing: 

Milk,   6  ounces    120 

Cream,  2  ounces   120 

Lactose,  2  ounces    240 

Coleman  suggests  the  following  diet :  ^ 


Hours. 

Milk,  6  ounces    9,  11   A.  m.  ;  3,  7  P.  M. 

Cream.  2  ounces 10  P.  M.;  1,  4  a.  m. 

Lactose,  10  grams. 


Total. 
1260  c.c. 
420  c.c. 
70  gm. 


1980 


At  11  A.  M.: 


At  5  P.  M. 


Calories. 
.      80 


Egg,   1    

Mashed  potato,  20  gm 20 

Custard,  4  ounces   250 

Toast   (or  bread),  1  slice....  80 

Butter,   20   gm 150 

Coffee. 

Cream,    2    ounces    120 

Lactose,  20  gm 80 


Egg,  1 
Cereal, 


Calories. 

80 

3   tablespoonfuls    ....  150 

Cream,  2  ounces    120 

Applesauce,  1  ounce   30 

Tea. 

Cream,  3  ounces   180 

Lactose,  20  gm 80 


780 


At   7   A.  M.: 
Egg,   1 


Toast,    1    slice    .  . 

Butter.  20  gm.    . 

Coffee. 

Cream,  2  ounces 

Lactose,   2  gm.    . 


640 
Calories. 
.      80 
.      80 
.    150 


1  Which  contains  3910  calories,  and  may  be  modified  as  desired. 


120 
80 

510 


380 


DIET  ly  DISEASE 


The  following  contains  5580  calories 


Milk,  5  ounces    9, 

Cream,   2   ounces    

Lactose,  15  gm. 


Hours. 
11   A.M.;  3,  7 
10  P.M.;   1,  4 


Total. 

Calories. 

200  c.c. 

820 

720  c.c. 

1440 

120  gm. 

480 

At    11    A.M. 


Calories. 

Eggs,    2    100 

Toast,  2  slices   IGO 

Butters  20  gm 150 

Mashed  potato,  70  gm 70 

Custard,  S  ounces   500 

1040 


2740 
At  5  p.  M.: 

Calories. 

Egg,   1   slice    80 

Toast,  2  slices   160 

Butter,  20  gm 150 

Cereal,  6  tablespoonfuls  ....  290 

Cream,  4  ounces    240 

Applesauce,  1  ounce   30 

Tea. 

Cream.  2  ounces    120 

Lactose,  20  gm 80 


At 


1150 

Calories. 
.      80 
.    160 
.    150 


7  A.  M. : 

Egg,  1    

Toast,  2  slices 

Butter,  20  gm 

Coffee. 

Cream,  3  ounces    180 

Lactose,  20  gm 80 

650 

The  following  diet  contains  5570  calories,  and  is  suitable  for  con 
valescents : 

Hours.  Total. 

Milk,  5  ounces   9,  11  A.M.;  1,  7  P.M.  1050  c.c. 

Cream,  3  ounces 10  P.  M.;   1,  4  a.  m.  630  c.c. 

Lactose,  15  gm.  105  gm, 


Calories. 

700 

1260 

420 


At  11  A.M.:  At 

Calories. 

Eggs,    2    160 

flashed  potato,  80  gm 80 

Custard,  8  ounces   500 

Creamed  chicken,  1  ounce...  50 

Toast,  2  slices 160 

Butter,  20  gm 150 


2380 
5  P.M.: 

Calories. 

Toast,  2  slices 160 

Cereal,  6  tablespoonfuls 290 

Cream,  2  ounces 120 

Lactose,  20  gm 80 

650 


1100 
At  3  P.  M. : 

Calories. 
Lemonade    ( lactose,  120  gm. )    480 

At   7   P.  M. :  Calories. 

Egg,   1    80 

Cereal,  5  tablespoonfuls    250 

Cream,  2  ounces   120 

Toast,  2  slices   160 

Butter,  20  g-m 150 

Coffee. 

Cream,  2  ounces 120 

Lactose,   20  gm 80 

960 


THE  FEEDING  I\  INFECTIOUS  DISEASES  381 

The  following  valuable  recipes  were  arranged  by  Miss  Edna  Cutler, 
and  are  from  .Coleman 's  article : 

Cocoa  with  milk : 

Calories. 

1  rounding  teaspoonful  of  cocoa    50 

2  ounces  of  milk-sugar   240 

4  ounces  of  milk   80 

2  ounces  of  cream    120 

490 
Mix  the  sugar  with  the  cocoa ;  cook  in  the  milk  until  dissolved.     Serve  with  the 
cream. 

Cocoa :  Calories. 

1  heaping  teaspoonful   of  cocoa    .50 

2  ounces  of  milk-sugar    240 

i  cup  of  water. 

3  ounces  of  cream    180 

470 
Mix  the  cocoa  and  sugar,  add  the  water,  and  boil.     Then  add  the  cream,  or 
use  less  cream  and  serve  with  whipped  cream. 

Coffee:  Calories. 

li   ounces   of   milk-sugar    180 

4  to  5  ounces  of  strong  coffee. 

2  ounces  of  cream    120 

300 
Plain  junket  or  rennet  custard: 

Calories. 
2.5  gm.  ( 1  ounce)  of  milk-sugar 100 

5  ounces  of  milk   100 

i  junket  tablet. 

1  ounce  of  cold  water. 
Few  drops  of  vanilla. 

200 
See  directions  for  cocoa  junket. 

Cocoa  junket:  Calories. 

1  teaspoonful  of  cocoa .50 

25  gm.  of  milk-sugar   100 

5  ounces  of  milk 100 

I  junket  tablet  dissolved  in  1  ounce  of  cold  water. 

250 

Mix  the  cocoa  and  sugar,  add  the  milk,  and  heat  lukewarm,  stirring  con- 
stantly; add  the  dissolved  junket,  stir  thoroughly,  and  leave  it  in  a  cool  place 
to  set. 

Soft  custard: 

Calories. 
1  cup  of  milk   160 

1  egg     80 

2  ounces  of  milk-sugar    240 

Speck  of  salt. 

2  to  3   drops  of   vanilla,   or  caramel   made   of   3   tablespoonfuls  of 

granulated  sugar    20  {  ? ) 

500 
Beat  the  egg  slightly,  add  the  sugar,  salt,  and   hot  milk  slowly.     Cook   in  a 
double  boiler,  stirring  constantly,  until  it  thickens  a  little   (if  cooked  too  long. 


382  DIET  IX  DISEASE 

the  custard  will  curdle,  but  may  become  smooth  again  if  set  in  a  dish  of  cold 
water  and  beaten  at  once).     Flavor  and  cool. 

To  make  caramel :     Put  the  sugar  in  a  pan  directly  over  beat  and  burn  until 
a  very  dark  brown.     Dissolve  in  hot  water  or  milk. 

Baked  custard: 

Calories, 

li  ounces  of  milk-sugar   160 

6  ounces  of  milk    120 

1  egg 80 

Nutmeg  or  vanilla. 
Speck  of  salt. 

360 
Beat  the  egg  slightly.     Warm  the  sugar  and  milk,  stirring  constantly,  add  to 
the  egg,  strain   into  a  custard  cup,  and  flavor.     Bake  in   a  pan  of  water  in  a 
moderate  over  until  a  knife  when  cut  into  it  will  come  out  clean    (thirty  min- 
utes to  one  hour). 

Bread  pudding: 

Calories, 
1^  ounces  of  milk  sugar  180 

6  ounces  of  milk   120 

1  egg     80 

1  slice  of  bread   ( f -inch  thick )    60 

J  ounce  of  butter  120 

560 
Spread  the  bread  with  butter  and  cut  into  squares.     Beat  the   egg   slightly; 
heat  the  milk  and  sugar,  stirring  constantly;   mix  with  the  egg  and  pour  over 
the  bread.     Grate  nutmeg  over  the  top,  and  bake  the  same  as  the  custard. 

Vanilla  ice  cream: 

Calories. 
4  ounces  of  cream   240 

2  ounces  of  milk    40 

2  ounces   of  milk-sugar      240 

Speck  of  salt. 

Few  drops  of  vanilla. 

520 
Mix  the  cream,  the  milk,  and  sugar,  and  heat,  stirring  constantly,  until  the 
sugar  is  dissolved.     Then  flavor,  cool,  and  freeze. 

Lemonade : 

Calories 
4  ounces   of  milk-sugar    480 

7  ounces  of  cold  water. 

2  tablespoonf uls  of  lemon- juice   ( or  to  taste ) . 

480 
Boil  the  sugar  and  water  for  two  minutes,  add  lemon-juice  to  taste,  strain, 
and  cool. 

Care  of  the  Mouth. — This  is  of  primary  importance.  If  begun 
early  and  persisted  in,  many  undesirable  mouth  conditions  can  be 
avoided.  If  the  mouth  is  in  good  condition,  the  patient  can,  as  a  rule, 
take  his  food  easily;  if  it  is  not,  the  greatest  difficulty  may  be  ex- 
perienced. After  each  feeding  the  mouth  should  be  cleansed  care- 
fully, a  proceeding  that  should  never  be  neglected.  If  the  patient  is 
strong  enough,  he  may  rinse  the  mouth  with  a  mild  antiseptic  solution 
— the  prescription  given  in  the  section  on   Tuberculosis  is  an  ad- 


THE  FEEDING  IN  INFECTIOUS  DISEASES!  383 

mirable  one.  Boric  acid  solutions  to  which  a  little  glycerin  and 
lemon-juice  have  been  added  or  one  of  the  prepared  mouth-washes 
diluted  with  water  may  be  used ;  diluted  hydrogen  peroxid  is  also 
serviceable.  If  the  patient  is  too  weak  to  do  this,  the  nurse  should 
swab  the  mouth.  The  physician  should  assure  himself  that  the  nurse 
is  carrying  out  his  orders  in  this  regard,  for  careless  nurses  are  often 
apt  to  neglect  this.  The  use  of  chewing  gum  is  of  value  in  keeping  the 
mouth  in  good  condition. 

Diet  in  Digestive  Disturbances. — In  cases  where  the  food  is  re- 
jected or  badly  borne  it  is  necessary  to  give  the  stomach  absolute  rest 
for  several  hours  or  more.  Then  very  small  quantities  of  egg-water, 
barley-water,  and  lemon-juice,  or  similar  preparations,  may  be  given. 
Panopepton  and  the  liquid  beef  preparations  are  useful  in  this  con- 
dition, and  may  be  served  with  cracked  ice  or  diluted  with  water. 
Weak  tea  or  red  wine  and  water  in  small  doses  are  useful,  especially 
if  there  is  diarrhea. 

Diarrhea  is  often  caused  by  the  use  of  milk  in  which  there  are 
large  numbers  of  bacteria.  Where  diarrhea  persists,  the  milk  used 
should  be  examined  and  sterilized  or  pasteurized  milk  used.  The 
effect  of  using  pasteurized  milk  in  such  cases  is  often  very  striking, 
as  has  been  shown  by  Edsall. 

For  the  diarrhea  an  ice-bag  to  the  abdomen  has  been  highly  recom- 
mended, but  is  seldom  well  borne.  Instead,  cloths  moistened  with 
cold  water  may  be  used. 

For  the  painful  and  troublesome  accumulation  of  gas  in  the  in- 
testine either  the  ice-bag  or  the  cold  applications  may  prove  beneficial. 
The  authors  have  obtained  excellent  results  from  the  use  of  turpentine 
stupes,  but  these  have  failed  in  the  hands  of  many  physicians.  When 
the  meteorism  is  due  to  the  imperfect  digestion  of  starch,  the  carbo- 
hydrates should  be  reduced  or  withdrawn ;  when  it  is  due  to  milk,  the 
form  in  which  this  is  given  should  be  changed  or  it  should  be  with- 
drawn altogether  for  a  time. 

Hemorrhage. — When  hemorrhage  from  the  bowel  occurs,  the  in- 
testinal tract  should  be  given  absolute  rest  for  a  number  of  hours. 
An  ice-bag,  cold  applications,  or  a  cold-water  coil  should  be  placed 
upon  the  abdomen.  To  relieve  the  thirst  the  patient  may  be  allowed 
to  suck  small  bits  of  ice,  or  ice-cold  water  or  cold  tea  may  be  given  in 
spoonful  doses.  After  some  hours  the  patient  may  be  given  a  tea- 
spoonful  of  cold  milk,  and  this  may  be  repeated  every  two  or  three 
hours.  Beyond  this,  if  the  bleeding  is  severe,  the  intestinal  tract 
should  be  given  complete  rest  for  twenty-four  hours  or  longer. 
Opium  or  morphin  may  also  be  used.  The  return  to  the  regular  fever 
diet  should  be  made  gradually  and  with  caution. 

Perforation. — ^When  perforation  occurs,  all  food  should  be  dis- 
continued and  surgical  treatment  instituted,  or  where  this  is  not  pos- 
sible, large  doses  of  morphin  or  opium  may  be  prescribed.     Following 


384  DIET  IX  DISEASE 

operation  the  diet  will  be  that  of  any  bowel  perforation  that  has  been 
operated  upon.  If  the  patient  rallies  without  surgical  intervention, 
or  when  this  has  been  found  impracticable,  food  may  be  given  after 
an  interval  of  twenty-four  hours,  but  only  in  very  small  quantities  at 
sufficiently  wide  intervals.  It  is  best  to  begin  with  teaspoouful  doses 
every  three  hours,  and  if  the  food  is  retained,  this  may  gradually  be 
increased.  Usually  food  is  rejected,  and  when  this  is  the  case,  the 
stomach  should  be  given  complete  rest,  for  feeding  only  tends  to 
aggravate  the  condition. 

Convalescence. — The  diet  during  the  first  weeks  of  convalescence 
requires  as  much  care  and  attention  as  it  received  throughout  the 
febrile  period;  in  fact,  since  these  patients  often  develop  a  ravenous 
appetite,  born  of  several  weeks'  milk  diet  and  fever,  even  greater  care 
is  necessary.  The  patient's  wishes  should  in  nowise  govern  his  diet, 
and  relatives  and  friends  should  be  cautioned  against  giving  the  pa- 
tient anything  not  ordered  by  the  physician.  Many  a  relapse  and 
death  has  been  caused  by  the  misguided  kindness  of  friends  and 
relatives  in  this  respect. 

When  there  has  been  severe  bowel  disturbance,  the  patient  is  to  be 
kept  on  a  liquid  diet  until  the  ninth  or  tenth  day  of  the  afebrile 
period.  After  mild  cases,  where  there  has  been  but  little  bowel  dis- 
turbance, changes  may  be  made  in  the  diet  after  the  fifth  or  sixth 
afebrile  day.  In  these  mild  cases  the  greatest  caution  is  required, 
as  they  are  often  quite  as  apt  to  do  badly  as  are  the  severe  ones,  and 
the  attendants  are  much  more  likely  to  be  careless  in  carrying  out 
instructions. 

The  first  addition  to  the  dietary  should  be  made  by  giving  a  piece 
of  zwieback  over  which  hot  milk  or  cream  has  been  poured.  If  de- 
sired, milk-toast,  milk  and  crackers,  or  junket  may  be  substituted  for 
this.  If  this  is  well  borne,  other  articles,  such  as  soft-boiled  eggs  or 
the  soft  part  of  oysters  if  they  are  in  season  and  can  be  obtained 
fresh,  may  be  added  from  day  to  day.  Thickened  meat  broths  con- 
taining well-boiled  rice  or  vermicelli  may  be  given.  Finely  scraped 
raw  beef,  reduced  to  a  pulp  in  the  manner  suggested  for  tuberculosis 
patients,  also  lends  variety. 

Tender  meats,  vegetables,  and  bread-stuffs  in  increasing  quantities 
may  be  allowed.  Roast  chicken,  squab,  or  partridge,  boiled  (white) 
fish,  such  as  trout ;  of  the  vegetables,  spinach,  cauliflower  tops,  aspara- 
gus-tips, purees  of  peas,  carrots,  or  tender  string-beans  or  artichokes, 
well-cooked  rice,  and  baked  potato  mashed  and  served  with  cream  or 
dish  gravy;  toast,  zwieback,  crackers,  and  the  crust  of  bread  may 
all  be  permitted.  If  the  condition  of  the  bowel  permits,  fruit-juices 
may  be  allowed,  as  well  as  a  baked  apple,  apple-sauce,  or  junket 
flavored  with  fruit.  Other  sick-room  delicacies  may  be  ordered  at 
the  discretion  of  the  physician.  Chops,  tender  steak,  and  roast  beef 
may  generally  be  given  in  the  third  afebrile  week  (ver>-  finely  divided 


THE  FEEDING  IN  INFECTIOUS  DISEASES  385 

meat  may  be  allowed  much  earlier),  and  the  diet  gradually  changed 
until  the  ordinary  diet  is  resumed.  For  some  time  after  an  attack 
of  typhoid  the  patient  should  be  instructed  to  exercise  care  in  the 
selection  of  his  diet,  and  especially  to  avoid  all  food  such  as  green 
fruit,  green  corn,  crabs,  and  the  like,  that  is  likely  to  cause  diarrhea. 

The  following  menu  for  the  first  week  of  convalescence  may  serve 
as  a  guide  to  the  inexperienced  physician,  and  may  be  altered  to  suit 
the  individual  case.  It  may  be  begun  about  the  fifth  or  sixth  afebrile 
day  in  mild  cases,  and  about  the  ninth  or  tenth  in  severe  cases. 
Milk  should  form  the  bulk  of  the  diet  at  this  period. 

First  Day. — Milk-toast  or  zwieback  covered  with  hot  milk  or  cream 
or  crackers  and  milk.     Beef-juice. 

Second  Day. — Chicken  broth  thickened  with  rice  or  vermicelli. 
(The  rice  should  be  boiled  thoroughly.)  Soft  parts  of  several  oysters, 
or  a  very  lightly  boiled  egg. 

Third  Day. — Junket,  a  meat  broth  thickened  with  well-cooked 
barley  (boiled  at  least  three  hours),  with  barley  flour,  or  with  stale 
bread-crumbs.     Wine-jelly.     Scraped  raw  beef. 

Fourth  Day. — Lightly  boiled  or  poached  egg.  Arrow-root,  barley 
gruel,  or  milk-toast.     Chicken-jelly. 

Fifth  Day. — Junket,  a  little  well-boiled  rice  with  a  small  amount 
of  finely  divided  roast  chicken,  sqiiab,  or  partridge,  preferably  the 
white  meat.     Apple-sauce  if  bowels  permit. 

Sixth  Day. — Scraped  beef,  poached  egg,  calves '-foot  jelly.  A 
baked  custard.     A  piece  of  toast  or  zwieback. 

Seventh  Day. — A  small  piece  of  finely  divided  broiled  chop  or  steak, 
bakad  potato.  A  baked  apple.  Well-boiled  rice  and  cream  for  break- 
fast.    Junket  for  supper. 

ATYPICAL  TYPHOID— COMPLICATED  TYPHOID 

There  are  two  classes  of  cases  in  which  especial  attention  to  the 
diet  is  required.  These  are:  (a)  atypical  typhoid,  cases  where  the 
fever  persists  for  weeks  as  practically  the  only  symptom;  and  (&) 
those  cases  that  have  run  their  course,  but  where,  owing  to  some 
complication,  most  frequently  the  presence  of  pus,  the  fever  remains 
high. 

The  first  class  are  often  associated  with  extreme  emaciation,  and 
the  fever  may  be  regarded  as  a  true  inanition  fever.  In  others  the 
emaciation  may  not  be  extreme,  but  the  fever  may  persist,  and  may 
not  disappear  until  the  patient  is  allowed  to  sit  up.  In  these  cases, 
after  sufficient  time  has  elapsed  for  healing  of  the  intestinal  ulcera- 
tions to  take  place;  and  if  there  are  no  other  symptoms  forbidding  it, 
the  diet  may  be  increased  in  the  same  way  as  during  an  ordinary  con- 
valescence. If  an  exacerbation  of  the  symptoms  occurs  and  the  fever 
increases,  it  is  an  indication  that  too  much  food  is  being  given. 

In  the  second  class  of  eases  there  may  be  extreme  emaciation,  with 
25 


386  DIET  I^  DISEASE 

the  development  of  abscesses  or  furuncles.  These  patients  may  be 
benefited  by  an  increase  in  the  diet,  for  some  of  them  do  not  seem  to 
be  able  to  assimilate  sufficient  nourishment  from  the  food-supply  to 
make  up  for  the  waste. 

In  any  case  where  there  is  fever  the  diet  should  be  watched  care- 
fully and  no  changes  be  made  unadvisedly. 

TYPHUS  FEVER 

The  diet  in  this  disease  is  the  same  as  in  all  acute  fevers;  typhus 
requires  no  especial  precautions,  such  as  are  needed  in  typhoid. 
During  the  acute  stage  of  the  disease  the  diet  should  be  liquid,  milk 
being  best.  When  this  is  not  well  borne,  liquid  substitutes,  such  as 
are  used  in  typhoid,  may  be  given.  The  food  should  be  administered 
at  regular  and  sufficiently  frequent  intervals — every  two.  three,  or 
four  hours,  according  to  the  quantity  the  patient  is  able  to  take  at 
one  time,  A  quart  of  milk  and  a  pint  of  animal  broth  may  be  con- 
sidered a  fair  amount  of  food  for  one  day.  "Water  should  be  given 
freely. 

Curschmann  calls  attention  to  the  fact  that  eggs  are  better  borne 
in  typhus  than  in  typhoid,  and  recommends  that  several  be  given  every 
day.  He  also  advises  the  use  of  solid  food,  even  during  the  period  of 
fever,  if  the  patient  is  able  to  masticate  and  swallow.  He  allows 
rolls,  zwieback,  chicken,  and  chopped  meat. 

As  a  rule,  the  patients  require  a  supporting  and  a  stimulating  diet 
from  the  outset.  Alcohol  may  be  given  when  the  pulse  and  the  gen- 
eral condition  demand  its  use.  Black  coffee,  especially  when  there  is 
a  tendency  to  stupor,  is  also  to  be  recommended. 

Complications  are  treated  in  the  same  way  as  when  they  occur  in 
typhoid.  During  convalescence  the  diet  should  be  increased  as  rapidly 
as  possible,  the  usual  care  being  observed  (see  the  section  on  the  Diet 
in  Fevers ) .  Alcohol  in  some  form  is  generally  necessary  at  this  time. 
The  form  in  which  it  is  to  be  given  may  be  governed  by  the  patient's 
taste,  and  the  amount  should  be  carefully  regulated  by  the  patient's 
condition. 

SMALL-POX 

The  diet  in  small-pox  is  similar  to  that  recommended  in  other  acute 
fevers.  The  only  point  to  be  noted  especially  is  that  the  supporting 
diet  should  be  begun  early,  as  in  the  severe  cases  the  extensive  sup- 
puration makes  a  large  drain  on  the  patient's  system. 

During  the  first  stage  of  the  disease  there  is  little  desire  for  food. 
The  diet  should  be  liquid,  and  consist  of  milk,  broths,  albumin-water, 
and  the  like.  Intense  thirst  is  generally  present,  and  this  may  be 
relieved  by  water,  lemonade,  or  the  carbonated  waters. 

When  the  initial  fever  subsides  and  the  patient  feels  improved,  it 


THE  FEEDiyG  IN  IXFECTIOUS  DISEASES  387 

is  well  to  allow  any  light  nutritious  food  he  may  desire — milk,  eggs, 
chops,  steak,  or  rare  roast  meat ;  bread  or  toast ;  and  the  more  easily 
digested  vegetables,  such  as  well-cooked  potato,  spinach,  celery,  aspara- 
gus-tips, cauliflower  tops,  and  the  like  are  all  suitable. 

^Vhen  the  second  period  of  fever  comes  on,  a  return  to  the  liquid 
diet  may  again  be  made.  The  diet  should  be  as  ample  as  possible, 
and  the  food  be  given  at  regular  intervals  every  two  or  three  hours 
during  the  day  and  every  three  or  four  hours  at  night.  Milk,  plain 
or  peptonized,  milk-punch,  raw  eggs,  egg  and  sherry,  and  the  various 
combinations  and  dishes  made  of  eggs  and  milk  should  be  given. 
Broths,  beef -juice,  and  the  like  may  also  be  added  (see  Recipes  in 
Appendix).  AYhen  there  is  marked  dysphagia,  as  there  is  apt  to 
be  in  all  severe  eases,  the  food  is  best  given  cold,  at  more  frequent 
intervals,  and  in  smaller  quantities.  Rectal  feeding  may  be  resorted 
to  in  some  cases. 

In  severe  cases  alcohol  is  required,  and  may  be  given  from  time  to 
time  as  the  condition  of  the  patient  demands.  AYhisky,  brandy,  and 
port  wine  are,  as  a  rule,  borne  best ;  the  whisky  or  brandy  should  be 
given  in  diluted  form,  combined  with  a  small  amount  of  glycerin  or 
syrup  to  avoid  irritating  the  throat.  Stimulants  may  be  added  to 
the  milk,  or  they  may  be  given  in  the  form  of  milk-punch  or  egg-nog, 
according  to  the  patient's  taste.  Alcohol  should  not  be  given  as  a 
routine  practice  in  all  cases,  as  was  formerly  done.  Mild  cases  and 
even  those  of  moderate  severity,  in  patients  under  twenty,  usually 
require  little  or  no  stimulation. 

During  the  convalescence  the  diet  may  be  increased  rapidly.  As 
soon  as  the  fever  declines,  meat  may  be  added  to  the  dietary,  and  when 
the  appetite  and  digestion  allow,  other  articles  of  diet  may  be  given. 

SCARLET  FEVER 

Some  difference  of  opinion  exists  regarding  the  value  of  diet  in 
preventing  nephritis  in  scarlet  fever.  A  careful  study  of  these  cases, 
however,  has  led  to  the  belief  that  a  strict  milk  diet  during  the  height 
of  the  disease  and  a  mixed  milk  and  farinaceous  diet  during  con- 
valesence  are  by  far  the  safest.  Ziegler,  reporting  an  experience  of 
twenty-one  years  with  231  cases  kept  on  an  exclusive  milk-diet,  did 
not  have  a  single  case  of  nephritis.  Previous  to  that  time,  on  a  mixed 
diet,  half  his  cases  developed  nephritis.  After  a  number  of  years  of 
favorable  experience  wuth  the  use  of  milk  diets  in  scarlet  fever,  we 
have  come  to  the  conclusion  that  while  the  diet  is  effective  in  prevent- 
ing the  late  cases  of  nephritis,  it  is  difficult  to  use  in  many  cases.  We 
have  recently  been  more  liberal — allowing  farinaceous  foods  and  al- 
most any  purin-free  food  low  in  nitrogen.  So  far  we  have  not  had 
any  untoward  results.  A  list  of  the  purin-free  foods  will  be  found  un- 
der the  heading  of  Purin  Metabolism.    The  milk  should  be  diluted  with 


388  DIET  ly  DISEASE 

lime-water  or  with  a  carbonated  water;  if  it  disagrees,  it  may  be 
peptonized,  either  partially  or  completely.  Kumiss  or  buttermilk, 
particularly  the  former,  may  be  given  as  a  change.  Although  they 
may  refuse  it  at  first,  children  often  learn  to  like  kumiss.  If  milk 
becomes  distasteful  or  disagrees,  it  may  be  mixed  with  barley-water 
or  arrow-root  gruel,  or  these  may  be  given  plain.  Oyster  or  clam 
broth,  the  oysters  or  clams  having  been  strained  out,  makes  a  pleasant 
change. 

For  the  thirst,  which  is  generally  great,  plain  or  carbonated  waters, 
barley-water,  orangeade,  or  lemonade  may  be  given  freely.  A  level 
teaspoonful  of  cream  of  tartar  stirred  into  a  glass  of  lemonade  is  a 
useful  diuretic  drink  if  albuminuria  is  present. 

Plain  vanilla  ice-cream  or  a  plain  lemon  ice  may  be  given  in  small 
quantities.  Finely  shaved  ice,  also  in  very  small  quantities,  and 
flavored  with  a  little  lemon-  or  orange-juice,  often  makes  a  most 
grateful  addition  if  angina  is  marked. 

Jaccoud  and  Baginsky  insist  that  scarlatinal  nephritis  may  gen- 
erally be  averted  if  a  milk  diet  is  adhered  to  for  several  weeks  in  all 
cases.  It  is  a  good  plan  to  let  the  diet  in  all  cases  be  as  simple  as 
possible  for  three  weeks,  and  then  to  make  additions  to  it  from  day 
to  day.  If  there  is  albuminuria  or  nephritis,  a  milk  and  farinaceous 
diet,  as  recommended  in  nephritis,  should  be  adhered  to.  If  there 
has  been  a  severe  albuminuria,  without  casts,  or  if  symptoms  of 
nephritis  have  appeared,  the  diet  should  be  licjuid  for  a  month  or 
six  weeks,  the  urine  being  carefully  watched  in  the  meantime.  Owing 
to  carelessness  in  regard  to  the  diet,  mild  cases  of  scarlatina  may  be 
followed  by  severe  nephritis. 

In  all  cases  the  diet  should  be  graduallj'  increased  from  day  to  day 
during  convalescence ;  the  following  may  serve  as  a  guide  to  the  order 
in  which  this  increase  may  be  made:  Milk-toast,  junket,  custard, 
farina  pudding,  oranges,  rice-pudding,  baked  apple,  bread  and  milk, 
sago  or  tapioca  pudding,  with  or  without  apple,  corn-starch  pudding, 
boiled  custard. 

The  return  to  meat  is  best  made  by  allowing  a  small  quantity  of 
boiled  or  baked  fish,  the  soft  parts  of  oysters,  very  soft-boiled  eggs 
first  and  then  the  lightest  and  most  easily  digested  meats,  chicken, 
raw  or  very  rare  beef  in  minute  quantities,  and  the  like. 

During  the  height  of  the  disease  and  throughout  convalescence 
meat-extracts  should  be  avoided,  as  they  contain  large  quantities  of 
meat  extractives,  which  are  liable  to  irritate  the  kidneys. 

Rest  in  bed  should  be  insisted  upon  until  the  fever  has  been  absent 
at  least  a  week.  In  mild  cases  of  scarlet  fever  stimulants  are  not 
required;  but  in  the  severe  cases,  where  there  is  adenitis,  marked 
angina,  or  sepsis,  alcohol  may  be  used  as  the  heart  and  general  condi- 
tion indicate  the  need  of  it.  (See  Alcohol  in  Fevers.)  Strychnin 
and  digitalis  are  also  useful. 


THE  FEEDING  IN  IXFECTIOIS  DISEAHES  389 

MEASLES 

In  measles  the  diet  is  similar  to  that  of  any  acute  fever.  The  food 
of  infants,  if  bottle-fed,  should  be  more  dilute  than  usual;  for  older 
children  an  exclusively  liquid  diet  is  indicated. 

Milk,  soups,  and  broths  may  be  allowed,  and  these  may  be  pepton- 
ized if  necessary.  The  food  should  be  given  at  regular  intervals,  these 
depending  on  the  amount  given  at  each  time — generally  two,  three, 
or  four  hours  apart. 

Thirst  may  be  allayed  by  water,  plain  or  carbonated,  orangeade, 
lemonade,  and  the  like.  The  return  to  a  solid  diet  should  be  made 
gradually.  Alcohol  may  be  vised  if  necessary.  When  gastro-intestinal 
disturbances  supervene,  they  should  be  treated  in  the  customary  way. 
(See  Feeding  in  Fever.) 

MUMPS 

While  fever  or  swelling  exists  the  diet  should  be  liquid.  During 
convalescence  some  solid  food  may  be  taken.  Care  should  be  observed 
to  avoid  all  acids  and  astringents,  as  these  may  cause  extreme  dis- 
comfort and  even  intense  pain. 

WHOOPING-COUGH 

In  all  cases  of  whooping-cough  the  diet  and  the  bowels  require  the- 
closest  attention. 

If  the  child  has  any  tendency  to  the  so-called  "mucous  disease" 
or  to  intestinal  disturbance,  this  is  almost  sure  to  manifest  itself  dur- 
ing the  course  of  the  disease,  as  all  the  mucous  membranes  are  ap- 
parently affected.  Attacks  of  indigestion  and  the  abdominal  disten- 
tion that  usually  follows  may  increase  the  number  of  paroxysms. 
There  is  always  a  tendency  to  vomit.  This  usually  occurs  with  or 
after  the  paroxysms  of  coughing,  but  the  pharynx  may  become  so  ir- 
ritable that  vomiting  may  be  excited  by  the  taking  of  food,  drink, 
or  medicine.  Any  drug  that  tends  to  produce  nausea  should  care- 
fully be  avoided. 

The  diet  for  children  under  two  years  of  age  should  be  fluid.  Milk, 
diluted  with  lime-water  or  a  carbonated  water,  or  peptonized,  should 
be  the  mainstay.  Broths,  albumin-water,  and  barlej^-water  are  also 
useful.  In  children  who  are  weak  or  in  whom  vomiting  is  severe, 
some  of  the  predigested  liquid  beef  preparations,  well  diluted  with 
water,  may  be  given.  These  are  stimulating  and  contain  considerable 
nutriment. 

Children  over  two  years  of  age,  if  the  case  is  severe,  should  be  put 
on  a  liquid  diet.  If  food  is  retained  and  vomiting  is  not  troublesome, 
semisolid  food  may  be  given ;  if  this  causes  no  disturbance,  easily 
digested  solid  food  may  be  allowed.  Kumiss  is  sometimes  of  value, 
and  custards,  barley,  oatmeal,  or  arrow-root  gruels,  broths,  junket, 
and  the  like  are  useful  in  varying  the  diet. 


390  DIET  IX  DISEASE 

If  much  difficulty  is  experienced  in  feeding  the  child,  the  food 
should  be  given  in  small  quantities  every  two  or  three  hours.  If 
vomiting  persists,  the  measures  recommended  in  the  section  on  Vomit- 
ing may  be  tried.  If  a  meal  is  vomited,  it  may  be  repeated  after  a 
short  interval.  Children  with  mucous  disease  should  receive  the  diet 
recommended  for  that  condition. 

In  weak  children  and  in  protracted  cases  alcohol  may  be  needed. 
This  may  be  given  in  the  form  of  liquid  beef  peptonoids,  panopepton, 
milk-punch,  egg-nog,  or  sherry  and  albumin-water.  In  many  cases 
it  is  desirable  to  give  only  the  stimulants,  and  in  these  cases  whisky 
and  sweetened  water  or  wine  may  be  given.  A  good  matured  whisky 
is  usually  the  most  satisfactory,  as  the  dosage  is  easier  to  manage  and 
the  effect  more  constant.  In  very  severe  cases  nutrient  enemata  may 
be  necessary. 

It  has  been  held  by  some  that  diet  has  a  specific  influence  on  the 
course  of  this  disease.  Hannon  claims  to  have  cured  cases  in  two 
weeks  by  a  "tonic  diet"  that  consisted  of  roast-beef  with  toast  and 
pure  Madeira  or  port  wine  in  the  morning ;  biscuit  and  wine  at  noon ; 
meat  broth,  roast  meat,  toast,  and  wine  in  the  afternoon;  wine  in 
the  evening,  and  cold  water  at  night.  He  allowed  no  milk,  vegetables, 
soups,  or  puddings. 

INFLUENZA 

The  diet  in  this  disease  should  be  that  recommended  in  all  acute 
febrile  conditions.  During  the  height  of  the  disease  the  food  should 
be  liquid,  and  be  given  in  small  quantities  and  at  regular  intervals. 
As  the  condition  improves  a  return  to  a  semisolid  diet  and  then  to 
solid  food  may  be  made.  Convalescence  is  apt  to  be  slow  and  tedious, 
and  during  this  period  easily  digested  nutritious  food  should  be  given 
in  as  large  quantities  as  the  patient  can  digest.  Milk  and  eggs,  either 
alone  or  combined  in  the  form  of  egg  or  egg-nog,  may  be  given  be- 
tween meals.  Alcohol  is  usually  indicated  throughout  the  disease, 
and  may  be  given  in  the  form  of  whisky  and  water,  wine,  or  malted 
liquors,  according  to  the  condition  and  tacte  of  the  patient.  If  con- 
valescence is  slow,  a  change  of  air  will  often  facilitate  recovery  and 
restore  the  appetite  and  strength. 

MENINGITIS  AND  CEREBROSPINAL  FEVER 
In  these  diseases  the  diet  is  that  of  all  acute  fevers.  The  food  may 
be  liquid  or  semisolid,  and  should  be  given  at  regular  intervals.  If 
the  patient  is  able  to  swallow,  several  ounces  may  be  given  at  a  time 
every  two  or  three  hours.  If  swallowing  is  difficult,  small  quantities 
of  predigested  food  may  be  given  at  very  short  intervals — every  half- 
hour,  or  if  it  is  given  only  a  teaspoonful  at  a  time,  as  frequently  as 
every  fifteen  minutes.  In  these  cases  the  food  may  be  given  with  a 
teaspoon  or  a  medicine-dropper.  In  some  cases,  where  it  does  not 
excite  convulsions,  a  stomach  or  nasal  tube  may  be  used. 


TEE  FEEDING  IN  INFECTIOUS  DISEASES  391 

If  the  patient  is  able  to  swallow,  liquids  and  semisolids  are  in- 
dicated. Water  may  be  given  freely,  and  as  the  patients  are  often 
unconscious  or  only  semiconscious,  water  should  be  given  as  a  routine. 
This  is  a  matter  that  is  frequently  neglected. 

Alcohol  may  be  used  when  the  pulse  and  general  condition  indicate 
the  need  for  stimulation.  During  the  acute  stage  it  is  usually  not 
required,  and  when  given  too  early  may  intensify  the  cerebral 
symptoms.  As  the  patient's  strength  fails  it  is  demanded  in  increas- 
ing quantities. 

The  convalescence  is  to  be  managed  as  after  any  acute  fever,  and  an 
abundance  of  food  should  be  allowed. 

DIPHTHERIA 

The  feeding  of  diphtheria  patients  is  carried  out  along  the  same 
lines  as  those  laid  down  for  acute  fevers  in  general.  Owing  to  the 
location  of  the  lesion  and  the  frequency  with  which  intubation  or 
tracheotomy  is  performed,  special  difficulties  arise,  and  must  be  met 
promptly  and  intelligently,  or  the  patient  may  succumb  rapidly. 

The  careful  management  of  the  diet  in  diphtheria  is  of  the  greatest 
importance.  If  the  patient's  nutrition  is  not  maintained,  the  body 
will  not  be  able  to  withstand  the  effects  of  the  poisons  that  are  intro- 
duced into  the  circulation. 

If  the  disease  occurs  in  a  nursing  infant,  Koplik  advises  that  the 
milk  be  drawn  from  the  breast  with  a  breast-pump  and  fed  to  the 
child  from  a  bottle  or  spoon.  This  is  done  to  avoid  infection  of  the 
breast.  If  the  mother  has  been  rendered  immune,  the  danger  of 
breast  infection  is  very  slight. 

In  all  cases,  if  there  is  any  fever,  the  food  should  be  liquid,  and 
should  be  given  in  small  quantities  at  regular  intervals.  The  most 
useful  of  the  liquid  foods  are  milk,  plain,  with  lime-water  or  a  car- 
bonated water,  or  peptonized  albumin-water ;  some  form  of  predigested 
beef,  as  Liquid  Beef  Peptonoids  or  Panopepton ;  soups  and  gruels  and 
the  various  prepared  foods  of  which  malted  milk,  Eskay's,  or  Mellin's 
foods  are  examples. 

Occasionally  semisolids  are  swallowed  with  greater  ease  than  liquids ; 
in  this  case  any  of  the  foods  just  mentioned  may  be  thickened  with 
well-cooked  cereals  or  gelatin,  or  custards  or  junket  may  be  given. 
Ice-cream,  if  plain,  may  be  allowed  in  small  quantities.  Egg-nog  and 
milk-punch  are  sometimes  useful,  although,  as  a  rule,  stimulants  are 
best  given  alone,  and  not  combined  with  the  food. 

If  the  patient  can  not  swallow,  nutrient  enemata  may  be  resorted 
to;  or,  as  recommended  by  Oilman  Thompson,  a  nasal  or  a  stomach- 
tube  may  be  employed.  If  the  latter  mode  of  feeding  is  adopted, 
care  should  be  taken  to  avoid  struggles  with  patients  whose  hearts 
are  weak. 

Intubation. — After  intubation  has  been  done  there  may  or  may  not 


392  DIET  7X  DISEASE 

be  some  difficulty  in  swallowing.  As  a  rule,  when  the  child  swallows 
for  the  first  time,  there  may  be  a  slight  cough  or  some  hesitation ;  in 
the  majority  of  cases,  however,  this  disappears  as  the  apprehension 
of  the  child  is  allayed.  There  may  be  a  little  difficulty  for  the  first 
day,  but  this  passes  off  gradually  as  the  muscles  become  accustomed 
to  work  under  the  new  conditions. 

Some  children  find  it  difficult  to  close  the  epiglottis  with  the  tube  in 
position,  and  hence  during  deglutition  some  of  the  food  is  likely  to  be 
drawn  into  the  larynx  or  even  into  the  lungs.  This  may  cause  dyspnea 
and  violent  coughing,  or  when  drawn  into  the  lung  may  give  rise  to 
pneumonia.  This  accident  is  not  very  likely  to  occur  if  perfectly 
made  tubes  are  used,  and  if  the  Drecaution  is  taken  to  press  the  tube 
well  into  place  before  the  mouth-gag  is  removed. 

O'Dwyer  believed  that  food  that  enters  the  tube  is  always  coughed 
up  and  never  causes  pneumonia.  He  recommended  that,  if  the  child 
is  old  enough,  he  be  instructed  to  take  the  food  as  rapidly  as  possiole 
and  then  to  cough  afterward,  instead  of  after  each  act  of  deglutition, 
as  he  is  apt  to  do.  In  some  children  there  vaay  be  a  slight  regurgita- 
tion through  the  nose.  Taken  all  in  all,  the  difficulty  experienced 
in  feeding  these  eases  is  small  compared  to  the  enormous  benefit  the 
child  derives  from  the  operation. 

If  there  is  difficulty  in  swallowing  liquids,  solid  or  semisolid  food 
may  be  given  instead.  Castelberry,  of  Chicago,  suggests  that  the 
child  be  placed  with  his  head  lower  than  his  body.  In  this  position 
swallowing  becomes  easy.  The  child  may  also  lie  across  the  nurse's 
lap  with  his  head  thrown  well  back  and  down.  It  should  always  be 
remembered  that  food  may  be  refused  because  of  nausea,  or  because 
the  child  has  no  desire  to  take  anything,  as  well  as  owing  to  any  actual 
difficulty  in  swallowing. 

The  diet  should  be  the  same  as  in  non-operative  cases,  and  if  semi- 
solids or  solids  are  required,  soft-boiled  or  poached  eggs,  milk-toast, 
custards,  junket,  bread  and  milk,  oatmeal  porridge,  and  similar  foods 
may  be  given. 

If  swallowing  becomes  impossible,  an  event  that  occurs  very  rarely, 
the  child  may  be  fed  with  the  stomach  or  nasal  tube  or  by  means  of 
nutrient  enemata. 

No  especial  dietetic  rules  are  necessary  for  feeding  tracheotomy 
cases. 

Postdiphtheritic  Paralysis. — In  paralysis  of  the  muscles  of  deglu- 
tition which  may  occur  after  diphtheria,  most  of  the  food  may  return 
through  the  nose;  or  if  the  muscles  of  the  tongue  as  well  as  the  soft 
palate  are  involved,  deglutition  becomes  impossible.  When  this  oc- 
curs, the  child  must  be  fed  with  the  stomach  or  nasal  tube  or  by  the 
rectum.     (See  Gavage) 

ERYSIPELAS 
The  diet  in  erysipelas  is  the  same  as  in  other  acute  fevers.     During 


THE  FEEDING  IN  INFECTIOUS  DISEASES  393 

the  height  of  the  disease  a  liquid  diet,  given  in  small  quantities  and 
repeated  at  short  and  regular  intervals,  is  recommended.  As  the 
patient  improves  a  gradual  return  may  be  made  to  the  ordinary  diet. 
Alcohol  is  useful,  and  patients  with  erysipelas,  like  those  with 
septicemia,  may  take  large  (juantities  without  producing  an  intoxicat- 
ing effect.  In  the  severe  forms  whisky  or  brandy  may  be  given  at 
regular  intervals  in  doses  sufficient  to  maintain  the  heart  action.  The 
effect  of  the  stimulation  should  be  watched  carefully  and  the  amount 
regulated  according  to  rules  previously  laid  down.  From  sixteen  to 
twenty- four  ounces  a  day  may  be  required. 

RHEUMATISM 

Acute  Rheumatism. — The  exact  relation  that  diet  bears  to  rheuma- 
tism has  not  been  proved,  and  the  statement  that  any  special  diet  may 
act  as  a  predisposing  factor  is  conjectural.  Improper  and  insuffi- 
cient food  are  responsible  only  in  so  far  as  they  lower  the  resistance 
of  the  body. 

During  the  acute  attack  the  management  of  the  diet  is  similar  to 
that  of  other  acute  fevers.  Some  diversity  of  opinion  exists  as  to 
what  constitutes  the  best  diet  in  these  cases.  Cheadle  allows  animal 
broths,  and  says  that  he  has  never  seen  any  advantage  result  from 
cutting  them  off  entirely.  Senator  prescribes  a  somewhat  more  liberal 
diet  than  is  given  in  other  acute  fevers. 

During  the  acute  stage  the  safest  place  is  to  put  the  patient  on  a 
milk  or  on  a  milk  and  farinaceous  diet.  If  the  patient  can  not  take 
milk,  oyster  or  clam  broth,  preferably  without  the  oysters  or  clams, 
raw  oysters,  milk-toast,  barley  or  arrow-root  gruel,  buttermilk,  kumiss, 
and,  if  these  are  not  sufficient,  soups  and  broths,  may  be  given.  It 
is  well,  so  far  as  possible,  to  avoid  animal  broths,  and  meat-extracts 
are  contraindicated. 

Thirst  is  usually  a  prominent  symptom,  and  for  this  bland  or  acid 
drinks  may  be  given  freely.  Lemonade  is  generally  serviceable,  es- 
pecially since  lemons  have  been  advocated  in  the  treatment  of  the 
disease.  Carbonated  water  or  Vichy  may  be  used,  and  milk  and  car- 
bonated water,  buttermilk,  or  kumiss  may  be  tried. 

Until  convalescence  is  fully  established, — that  is,  for  a  week  or  ten 
days  after  the  fever  has  subsided, — the  patient  should  be  fed  only 
milk  and  farinaceous  food.  The  return  to  solid  food  should  be  grad- 
ual. Fish,  oysters,  and  eggs  should  be  added  first,  followed  by  chicken 
and  later  by  other  meats.  Vegetables  may  be  added  at  the  same 
time,  the  more  easily  digested,  such  as  well-baked  potato  and  well- 
cooked  spinach,  cauliflower  tops,  stewed  celery,  and  the  like,  being 
chosen  first.  Sweets  are  to  be  avoided,  but  fresh  fruit  may  be  taken. 
The  patient's  strength  should  be  fostered,  and  if  there  is  anemia,  the 
return  to  the  more  easily  digested  animal  foods  should  not  be  delayed 
too  long. 


394  DIET  IX  DISEASE 

The  meals  should  not  be  of  sufficient  size  to  tax  the  patient's  diges- 
tion, and  may  be  supplemented  by  two  or  three  extra  glasses  of  milk 
a  day,  served  with  a  piece  of  toast  or  a  biscuit,  or  by  an  egg-nog  or  a 
cup  of  vegetable  broth. 

Alcohol  is  contraindicated  in  the  acute  stage  of  the  disease,  but 
may  be  prescribed  for  very  weak  patients  and  where  cardiac  complica- 
tions indicate  its  use.  During  convalescence,  if  there  is  continued 
weakness,  it  may  be  employed. 

Chronic  Rheumatism. — Where  the  disease  is  chronic,  the  diet 
should  be  as  nourishing  as  possible.  As  a  rule,  sweets  and  meat  are 
best  avoided.  Fish,  eggs,  oysters,  and  the  lighter  meats,  all  farina- 
ceous foods,  and  the  more  digestible  vegetables,  particularly  the  green 
ones,  may  be  allowed.  When  the  patient  is  very  weak  and  anemic, 
alcohol  may  be  given  if  desired;  in  other  cases,  where  the  tonic  or 
stimulant  effect  is  not  especially  indicated,  it  is  to  be  avoided.  Care 
should  be  taken  not  to  mistake  this  condition  for  gout  or  for  arthritis 
deformans,  as  is  so  frequently  done. 

ASIATIC  CHOLERA 

Infection  with  the  cholera  spirillum  takes  place  through  the  mouth, 
and  is  usually  caused  by  drinking  contaminated  water.  Infection 
may  also  be  conveyed  by  milk  and  by  raw  vegetables,  by  touching  a 
contaminated  object,  and  by  similar  methods.  The  disease  may  be 
carried  by  flies,  and  thus  milk  and  other  foods  may  become  infected. 

During  a  cholera  epidemic  the  following  prophylactic  measures 
are  to  be  carried  out.  Only  the  more  important  ones  will  be  men- 
tioned here ;  for  a  detailed  study  of  this  subject  the  reader  is  referred 
to  works  on  Hygiene  and  on  Public  Health : 

Fatigiie,  mental  worry,  and  anything  that  lowers  the  mental  or 
physical  tone  should  be  avoided. 

All  exhausting  exercises  should  be  excluded,  and  alcohol  taken  but 
sparingly,  if  at  all.  Disturbances  of  the  stomach  or  bowels  should 
receive  prompt  treatment,  and  active  purgation  should  be  avoided. 

All  food  should  be  cooked  and  all  beverages  boiled,  with  the  excep- 
tion of  those  bottled  and  known  to  be  absolutely  free  from  any  pos- 
sible contamination  with  the  cholera  spirillum.  Coffee  and  other 
similar  beverages  should  be  made  from  boiled  water.  Ice  should  be 
made  from  distilled  water,  or  when  this  is  not  practicable  should  not 
be  used  in  any  article  of  food  or  drink.  Only  boiled  water  should 
be  used  for  cleansing  the  teeth. 

All  raw  vegetables  and  all  food,  such  as  fish  or  shell-fish,  that  may 
be  partly  decomposed,  should  be  avoided.  Care  should  be  taken  to 
secure  pure  milk. 

Any  article  of  food  liable  to  produce  indigestion  or  diarrhea  should 
not  be  eaten. 

Since  the  micro-organism  causing  cholera  will  not  thrive  in  an 


THE  FEEDING  IN  INFECTIOVH  DISEASES  395 

acid  medium,  acid  drinks  are  a  useful  preventive  measure  against 
infection.  Lemonade  made  with  aromatic  sulphuric  acid  or  dilute 
sulphuric  acid  has  been  widely  recommended.  Ten  or  fifteen  drops 
of  the  acid  should  be  added  to  a  glass  of  water.  Phosphoric  acid 
and  lime-juice,  as  well  as  vinegar  and  pickles,  are  also  used.  Care 
should  be  taken  not  to  disturb  the  digestion  by  taking  too  much  acid, 
and  it  should  be  taken  through  a  tube,  to  protect  the  teeth. 

The  disease  is  usually  divided  into  four  stages;  this  division  is, 
however,  arbitrary.  These  stages  are :  a  premonitory  diarrhea,  a 
severe  diarrhea,  a  stage  of  collapse,  and  a  reactionary  stage.  The 
mildest  cases  pass  through  only  the  first  and  the  second  stage.  The 
diet  for  each  stage  will  be  indicated  further  on.  In  addition  to  the 
diet,  certain  general  indications  for  treatment  may  be  mentioned. 
Kenneth  MacLeod  has  summarized  these  somewhat  as  follows: 

The  patient  should  be  put  to  bed  and  kept  absolutely  quiet.  The 
preliminary^  diarrhea  should  be  checked  as  soon  as  possible.  As  the 
circulation  fails  stimulants  should  be  given.  If  the  temperature  is 
excessive,  it  should  be  reduced ;  if  the  bodily  heat  is  lowered,  it  should 
be  raised. 

Any  persistent  diarrhea  should  be  checked ;  any  tendency  to  vomit- 
ing should  be  relieved  if  possible.  Thirst  should  be  allayed,  and  pain 
and  distress  alleviated  so  far  as  possible. 

During  the  stage  of  diarrhea  little  or  no  food  should  be  given. 
Acid  drinks,  and  sulphuric  acid  especially,  may  be  administered.  If 
food  is  taken,  it  should  be  given  in  very  small  quantity,  and  in  the 
form  of  albumin-water,  beef-juice  or  predigested  beef  solutions,  barley- 
or  oatmeal-water,  or  whey.  Milk  is  best  avoided,  for  if  it  is  not  di- 
gested or  absorbed,  it  forms  a  most  excellent  culture-medium  for  the 
development  of  the  cholera  spirillum.  If  it  is  given,  it  should  first 
be  peptonized.  Tea  in  small  (quantities  may  be  allowed  if  desired, 
or  a  little  red  wine  (claret)  may  be  administered. 

In  the  second  stage  continuous  purging  and  vomiting  generally 
occur.  Morphin  hypodermically  is  probably  the  best  means  of  check- 
ing these  symptoms.  A  mustard-plaster  over  the  abdomen  may  give 
some  relief,  or  turpentine  stupes  may  be  applied.  During  this  stage 
no  food  should  be  given,  for  it  will  be  rejected.  Thirst  should  be 
allayed  as  far  as  possible  by  any  of  the  following  articles,  given  in 
very  small  quantities  and  at  ten-  or  fifteen-minute  intervals :  Cracked 
ice,  cold  water,  cold  acid  water  (dilute  phosphoric  or  sulphuric  acid 
diluted  with  water),  carbonated  water,  iced  lemonade,  or  lime-juice. 
Weak  tea  or  strong  black  coffee  may  also  afford  relief.  If  vomiting 
continues,  thirst  may  be  assuaged  by  allowing  the  patient  to  hold 
a  little  iced  lemonade  or  iced  water  in  the  mouth  without  swallow- 
ing it. 

If  morphin  does  not  check  the  vomiting,  it  may  sometimes  be  re- 
lieved by  washing  out  the  stomach  with  normal  salt  solution  or  with 


396  DIET  ly  DISEASE 

weak  boric  acid  solution.  If  the  fluid  in  the  patient's  body  is  much 
reduced  and  the  patient  passes  into  the  third,  or  algid,  stage,  injec- 
tions of  normal  salt  solution  may  be  given  subcutaneously  or  intrave- 
nously. By  this  means  a  patient  is  often  revived,  but,  unfortunately, 
the  permanent  relief  hoped  for  by  this  method  of  treatment  has  not 
been  attained. 

When  the  vomiting  ceases  and  the  severe  symptoms  begin  to  sub- 
side, small  quantities  of  food  may  be  given.  At  first  a  teaspoonful 
every  fifteen  minutes  may  be  tried ;  and  if  this  is  retained,  the  quantity 
may  be  increased  and  the  interval  lengthened.  Albumin-water,  pep- 
tionized  milk,  and  beef -juice  or  predigested  beef  solutions  should  be 
given  at  first.  The  stomach  often  remains  irritable  for  days  and 
weeks  after  an  attack,  and  great  care  should  be  exercised  not  to  excite 
diarrhea  or  vomiting.  Stimulants,  in  the  form  of  small  doses  of 
iced  champagne  or. diluted  brandy  or  whisky,  may  be  administered. 

The  convalescence  should  be  conducted  as  after  typhoid  fever, 

YELLOW  FEVER 

This  disease  is  usually  described  as  presenting  three  stages:  the 
period  of  invasion  and  fever,  followed  by  a  period  of  calm  or  re- 
mission. Many  mild  cases  recover  without  passing  into  the  third 
stage,  which  is  merely  an  exacerbation  of  the  second  stage,  and  is 
accompanied  by  black  vomit  and  frequently  by  uremia  and  collapse. 

Almost  all  writers  agree  as  to  the  necessity  of  withholding  all  food 
for  the  first  seventy-two  hours  of  the  disease.  At  the  outset  it  is  well 
to  give  an  enema  and  two  or  three  grains  of  calomel,  followed  by 
absolute  rest  of  the  stomach  so  far  as  the  giving  of  food  is  concerned. 
As  most  of  the  subjects  of  yellow  fever  are  in  robust  health  when 
stricken,  the  starvation  is  well  borne.  If  food  is  given,  it  is  almost 
certain  to  be  rejected  and  to  aggravate  the  symptoms.  During  this 
period  Sternberg  recommends  the  following  mixture: 

Sodium  bicarbonate   50  grains 

Mercury  bichlorid     J  grain 

Water      40  ounces. 

Of  this,  three  tablespoonfuls  are  to  be  given  ice-cold  every  hour; 
a  treatment  that  has  been  highly  praised.  Touatre  is  a  firm  believer 
in  the  efficacy  of  Vichy  (Celestins),  and  administers  one  or  two  bottles 
a  day.  Absolute  rest  and  an  abundance  of  fresh  air  are  essential 
adjuncts  to  the  treatment.  If  Vichy  can  not  be  obtained,  soda-water, 
one  dram  to  a  quart  of  cold  water,  may  be  used  instead. 

If  vomiting  is  severe,  the  stomach  should  be  given  absolute  rest  and 
salt  solution  be  administered  by  the  rectum ;  or  if  the  rectum  becomes 
irritable  and  the  patient  should  become  algid,  the  injections  may  be 
given  intravenously,  as  recommended  in  cholera. 

During  the  third  day,  if  the  temperature  falls  below  102°  F.,  a 


THE  FEEDIXG  IX  lyPECTIOUS  DISEASES  397 

small  quantity  of  milk  and  lime-water  may  be  given  every  four  hours. 
This  is  more  likely  to  be  retained  if  taken  cold.  Gruels,  paps,  and 
the  like  should  be  avoided,  and  nothing  but  milk  and  lime-water  or 
albumin-water  may  be  allowed.  Tea  and  other  beverages  may  excite 
vomiting.  Anderson,  however,  suggests  one  small  cup  of  freshly  pre- 
pared tea,  drawn  but  a  minute  or  two,  to  be  taken  in  the  morning 
to  refresh  the  patient.  All  solid  food  should  be  forbidden  until  con- 
valescence is  well  established,  as  very  slight  indulgences  have  resulted 
fatally. 

If  the  patient  gets  worse  instead  of  better,  and  if  vomiting  begins 
again  and  the  diarrhea  is  severe,  all  food  will  be  rejected.  Iced 
champagne,  Rhine  wane,  or  brandy  and  water  may  be  administered 
in  small  quantities  at  frequent  intervals.  Black  coffee  may  also  be 
employed.  Cracked  ice,  soda-water,  lime-water,  Vichy,  or  the  car- 
bonated waters  may  be  given  a  trial.  Thirst  may  be  somewhat  re- 
lieved b}^  allowing  lemonade  or  dilute  acid  solutions  to  be  held  in  the 
mouth  rather  than  swallowed.  Subcutaneous  injections  of  normal 
salt  solution,  or  in  very  severe  cases  intravenous  injections,  may  be 
tried.  Mustard  paste  may  be  applied  over  the  epigastrium  or  turpen- 
tine stupes  may  be  ordered.  Morphin  hypodermically  is  more  effi- 
cient in  relieving  the  vomiting  than  any  other  drug. 

If  the  severe  symptoms  abate,  nourishment  may  again  be  attempted. 
A  teaspoonful  of  albumin-water,  with  or  without  a  little  dilute  brandy 
or  champagne,  or  the  same  quantity  of  peptonized  milk  or  of  predi- 
gested  beef-solution,  may  be  given.  If  this  is  retained,  it  may  be 
repeated  in  from  twenty  minutes  to  half  an  hour,  the  quantity  being 
graduall}-  increased  and  the  interval  lengthened  to  two  hours.  The 
stomach  is  apt  to  be  irritable  for  days,  and  the  food  must  be  liquid 
and  often  predigested.  Peptonized  milk,  albumin-water,  chicken-broth 
without  fat,  and  similar  fluids  may  be  given.  The  convalescence  is 
to  be  conducted  as  after  typhoid  fever. 

DENGUE 

The  diet  in  this  disease  is  that  of  an  acute  fever.  For  the  thirst, 
freshly  prepared  and  iced  carbonated  water  may  be  given.  Alcohol 
is  not  usually  required,  except  in  habitues,  and  is  best  avoided  in  the 
early  stages.     Severe  cases  should  be  treated  like  yellow  fever. 

MALARIA 

During  the  attack  of  an  intermittent  fever  the  stomach  is  generally 
irritable,  and  if  food  is  given  it  is  likely  to  be  vomited.  If  the  patient 
has  any  desire  for  food,  milk,  broths,  or  gruels  may  be  allowed. 
When  the  appetite  returns,  the  customary  diet  may  be  resumed. 
The  diet  should  be  varied,  and  fruit  and  green  vegetables  administered 
to  counteract  the  constipation  that  is  usually  present.  The  anemia 
that  follows  repeated  attacks  of  malaria  often  requires  an  especially 


398  DIET  IX  DISEASE 

nutritious  and  invigorating  diet,  such  as  is  prescribed  in  the  con- 
valescence from  fevers  in  general. 

In  the  prolonged  and  more  or  less  continuous  malarial  fevers  the 
diet  is  similar  to  that  of  any  acute  fever.  Alcohol  may  be  given  in 
the  convalescence  following  the  severer  forms.  Whisky  is  a  popular 
adjunct  to  treatment,  and  care  should  be  exercised  that  too  much  be 
not  taken  and  injurious  habits  formed. 

SPRUE 

This  is  a  disease  seen  chiefly  in  the  tropics  and  is  due  to  a  monilia 
infection.  The  disease  is  a  very  variable  one  and  its  treatment  seems 
to  consist  of  placing  the  patient  upon  a  diet  more  or  less  free  from 
sugars  and  starches,  inasmuch  as  the  monilia  ferments  these  and  so 
causes  a  diarrhea.  Several  methods  are  used;  one  is  to  place  the 
patient  upon  a  strict  milk  diet.  The  patient  is  first  given  castor  oil 
or  some  other  purge  and  is  then  placed  upon  varying  quantities  of 
milk,  usually  from  eight  to  twelve  ounces  every  two  hours.  During 
this  milk  diet  period,  which  is  usually  kept  up  for  eight  days,  the 
patient  should  be  kept  quiet,  but  not  necessarily  in  bed.  The  castor 
oil  is  usually  repeated  twice  a  week.  Cultures  of  the  Bulgarian 
strain  of  the  lactic  acid  bacillus  may  be  added,  particularly  where 
the  patients  do  not  tolerate  milk  well.  After  the  tenth  day  Ashford 
recommends  the  addition  to  the  diet  of  bananas,  the  amounts  being 
gradually  increased,  as  is  also  the  amount  of  milk.  After  varying 
lengths  of  time,  generally  a  month,  salads  and  other  fruits  and  meats 
are  added,  taking  care  to  see  what  effect  they  have,  but  sugar  is  gen- 
erally withheld  for  at  least  six  months  or  longer. 

In  cases  in  which  the  milk  is  not  well  borne  the  patient  is  put 
upon  a  strict  meat  diet,  the  meat  being  chopped  and  generally  served 
lightly  browned  and  hot.  About  two  pounds  may  be  given  in  a  day 
at  three-hour  intervals  for  six  meals.  The  meat  should  be  preceded 
by  the  administration  of  some  ten  ounces  of  water.  After  the  first 
week  salads  and  fruits  may  generally  be  added. 

Fruit  diets  and  vegetable  diets  have  been  used  in  still  other  cases. 
It  would  seem  that  the  carbohydrate-free  diets  of  diabetes  may  be 
utilized  in  the  treatment  of  this  disease  to  advantage. 

TETANUS 

In  all  cases  of  this  disease  the  efforts  should  be  directed  toward 
supplying  the  patient  with  the  largest  possible  amount  of  nourishment. 
Many  eases  die  from  exhaustion,  due,  in  part,  to  lack  of  food.  The 
difficulties  of  feeding  a  lock-jaw  patient  can  be  appreciated  only  by 
one  who  has  managed  a  severe  case.  Extreme  emaciation  and  marked 
anemia,  the  result  of  insufficient  nutriment,  are  generally  present. 

When  the  disease  is  not  severe,  liquid  nourishment  can  usually  be 
given  without  difficulty  by  allowing  the  food  to  pass  between  the 
teeth.     This  is  rendered  easier  when  a  tooth  is  missing.     If  the  teeth 


THE  FEEDING  IN  INFECTIOUS  DISEASES  399 

are  so  regular  aud  fit  so  closely  together  as  to  keep  all  food  out, 
nasal  or  rectal  feeding  may  be  tried.  lu  these  cases  food  should  be 
given  every  one  or  two  hours,  and  from  one  to  several  ounces  should 
be  taken  at  a  time.  Milk,  which  should  be  partially  peptonized,  milk- 
punch,  egg-nog,  albumin-water,  panopepton  and  water  or  any  reliable 
liquid  predigested  beef,  meat  broths,  and  stimulants  should  be  ad- 
ministered. Milk,  if  it  agrees  with  the  patient  and  can  be  given  in 
sufficient  quantities,  is  very  useful. 

In  severe  cases  any  attempt  to  handle  the  patient  or  to  feed  him  is 
likely  to  bring  on  a  convulsion.  This  is  as  true  of  rectal  feeding  as  of 
mouth-feeding.  In  some  cases  rectal  feeding  may  be  successful.  In 
these  difficult  cases  anesthesia  may  be  induced  by  chloroform,  and  if 
the  jaws  relax  sufficiently,  a  stomach-tube  may  be  passed  and  a  pint 
of  predigested  food  and  stimulant  poured  into  the  stomach.  In  many 
cases  a  nasal  tube  can  be  used  to  good  advantage. 

RABIES 

The  management  of  the  diet  in  rabies  is  substantially  the  same  as 
in  tetanus.  In  most  cases  even  the  slightest  movements  about  the 
patient  may  excite  violent  spasms.  When  this  is  the  ease,  all  at- 
tempts at  feeding,  whether  by  mouth,  nasal  tube,  or  rectum,  must  be 
discontinued.  Osier  has  suggested  that  the  throat  be  cocainized  so 
as  to  lessen  the  spasms  and  permit  the  patient  to  swallow.  Whenever 
possible,  this  should  be  done,  but  it  can  not  generally  be  accomplished. 
If  the  patient  is  suffering  from  hunger,  chloroform  may  be  adminis- 
tered by  inhalation  to  the  point  of  relaxation,  and  food  be  given  by 
the  stomach-  or  nasal  tube  or  by  the  rectum.  Since  all  cases  of  rabies 
are  fatal,  the  patient's  sufferings  should  not  be  augmented  by  in- 
effectual efforts  to  administer  food.  One  who  has  never  seen  a  case 
of  rabies  can  not  realize  the  extent  of  the  suffering  that  attempts  at 
feeding  may  induce. 

TUBERCULOSIS 

The  importance  of  proper  diet  in  tuberculosis  has  been  dwelt  upon 
since  the  time  of  Hippocrates.  Aretaeus  mentions  the  use  of  milk  in 
the  treatment  of  phthisical  patients.  Quotations  pregnant  with  facts 
relating  to  the  value  of  proper  food  might  be  added  from  almost  every 
medical  writer  of  prominence.  Osier  sums  up  the  matter  as  follows: 
"As  a  healing  of  a  tuberculous  process  is  largely  dependent  upon  the 
state  of  nutrition,  the  question  of  diet  becomes  of  the  very  first  im- 
portance. ' ' 

In  a  disease  with  such  protean  manifestations  there  are  many  points 
that  must  be  considered.  As  the  malady  usually  attacks  the  lungs, 
this  section  will  deal  principally  with  pulmonary  tuberculosis,  for  if 
the  dietetic  management  of  a  case  of  pulmonary  phthisis  is  understood 
thoroughly,  there  will  be  no  difficulty  in  modifying  it  to  meet  the  re- 
quirements of  other  forms  of  the  disease. 


400  DIET  IN  DISEASE 

From  the  outset  the  patient  must  be  impressed  with  the  fact  that 
diet  is  of  primary  importance  in  the  treatment  of  the  disease,  and 
whenever  he  displays  a  tendency  to  become  careless  in  this  regard, 
the  injunctions  concerning  diet  must  be  repeated.  Directions  should 
not  be  given  in  a  general  way,  but  should  be  specific,  covering  both 
the  articles  to  be  eaten  and  those  to  be  avoided.  The  time  for  taking 
food  and  the  amount  to  be  taken  should  be  carefully  outlined.  These 
points  vary  with  different  patients,  but  each  case  must  be  studied 
individually  if  success  is  to  be  attained.  It  is  generally  better  to 
give  written  instructions  concerning  the  diet,  as  the  patient  is  apt 
to  be  forgetful,  especially  if  he  has  certain  strong  likes  and  dislikes. 

Care  should  be  taken  to  give  only  such  directions  as  the  condition 
of  the  patient  will  warrant  carrying  out.  A  good  diet  and  fresh  air 
at  home  are  to  be  preferred  to  starvation  in  a  more  suitable  climate. 
The  patient  should  not  be  permitted  to  spend  too  much  of  his.  money 
on  railroad  fare  and  too  little  on  food. 

While  this  is  true,  one  should  not  lose  sight  of  the  fact  that  to 
obtain  the  best  results,  the  patient  must  have  an  abundance  of  fresh 
air,  and  carefully  regulated  hours  of  rest  and  exercise,  and  the  whole 
life  must  be  so  ordered  as  to  secure  as  great  freedom  from  care  and 
worry  as  is  possible. 

The  necessity  of  studying  individual  requirements  is  very  great, 
and  the  best  results  are  obtained  where  the  physician  directs  the  diet 
and  life  of  the  patient  with  professional  skill  and  common  sense.  In 
a  general  way  it  may  be  stated  that  no  tuberculosis  patient  can  get 
along  on  too  little  food,  and  this  has  led  to  rather  universal  overfeed- 
ing, and  many  overeat,  and,  indeed,  with  some  physicians  and  some 
patients,  overeating  becomes  a  fixed  idea. 

The  aim  should  be  to  cure  the  patient,  and  not  to  make  what  some 
one  has  termed  a  flabby,  breathless,  inert  mass.  A  smaller  diet,  well 
digested  and  assimilated,  is  much  better  than  overfeeding.  Hyperali- 
mentation may  be  used  in  certain  cases  under  supervision,  but  it  often 
leads  to  gastric  and  intestinal  irritability,  with  vomiting  and  diarrhea, 
foul  breath,  coated  tongue,  drowsiness,  headaches,  and  in  some  pa- 
tients there  may  be  an  unfortunate  obesity. 

The  best  diet  for  a  tuberculous  patient  has  not  been  definitely  de- 
termined, but  valuable  work  has  been  done  along  this  line,  and  the 
subject  is  much  better  understood  than  it  was  a  few  years  ago.  The 
question  resolves  itself  into  what  foods  are  best  for  the  tuberculosis 
patients,  and  how  much  should  they  be  given.  In  other  words,  what 
amounts  of  protein,  carbohydrates,  and  fats  will  give  the  best  results. 
It  is  manifestly  impossible  to  make  a  definite  dietary  for  a  disease  in 
which  the  conditions  are  necessarily  so  variable,  but  some  general 
deductions  may  be  made  which  may  serve  as  a  standard  and  as  a 
point  of  departure  for  individualizing. 

As  regards  the  amount  of  protein  food  required,  there  are  different 


THE  FEEDING  IN  INFECTIOUS  DISEASES  401 

opinions.  Nitrogen  equilibrium  maj^  be  established  and  maintained 
at  various  levels,  from  as  low  as  50  or  60  grams  of  protein  for  the 
average-sized  individual  up  to  120  grams  as  an  average  amount,  and 
beyond  this  to  some  150  or  160  grams  a  day,  although  these  latter 
amounts  may,  in  some  individuals,  cause  symptoms.  The  lower  fig- 
ures are,  undoubtedly,  too  low  for  the  consumptive,  and  perhaps  the 
best  results  are  obtained  by  the  higher  figures,  as  full  amounts  of 
nitrogenous  food  undoubtedl}'  stimulate  the  body's  power  of  resist- 
ance. Too  high  nitrogen  intake  causes  unnecessary  wear  and  tear  on 
the  organs,  and  the  amount  should  never  be  so  great  as  to  cause  the 
S3'mptoms  commonly  described  by  the  term  "biliousness."  Bardswell 
and  Campbell,  as  the  result  of  careful  feeding  with  weighed  diets, 
have  suggested  that,  as  a  rule,  the  protein  should  be  increased  about 
30  per  cent,  above  what  would  be  indicated  for  the  patient  if  in  health 
under  conditions  of  repose — i.  e.,  up  and  about,  but  not  doing  muscu- 
lar labor — and  this  increase  should  be  maintained  until  the  disease 
has  entirely  disappeared.  If  the  patient  is  under  weight,  there  should 
be  a  30  per  cent,  increase  either  in  carbohydrates  or  fats,  or  partly  of 
each,  until  the  patient  has  gained  a  few  pounds  more  than  the  normal 
weight  before  being  infected,  unless  this  weight  should  have  hap- 
pened to  be  an  abnormally  high  one,  as  in  the  obese.  When  this 
point  is  reached,  a  15  per  cent,  decrease  may  be  made,  and  this  diet 
continued  until  the  patient  is  cured.  In  an  average-sized  individual 
this  brings  the  total  food  intake  up  to  about  3500  calories  per  day. 
King  has  suggested  that  the  amount  of  food  taken  should  be  between 
30  and  40  calories  per  kilo  of  body  weight.  Large,  vigorous  in- 
dividuals, with  good  digestive  powers,  may  take  more,  while  smaller 
individuals  and  those  who  lead  sedentarj^  lives,  require  less.  Women, 
as  a  rule,  require  slightly  less  food  than  men  of  the  same  size  and 
weight. 

Diets  low  in  protein  are  not  suitable  for  consumptives,  and  insuffi- 
cient diet,  which  is  very  often  due  to  poverty  or  ignorance  of  how  to 
buy  and  prepare  food,  is  a  frequent  cause  of  failure  in  treatment. 
If  the  tuberculous  patient  is  unable  to  secure  a  sufficient  nutritious 
food,  his  chances  of  recovery,  or  even  of  maintaining  a  fair  degree 
of  bodily  health  and  efficiency,  are  very  slight.  Insufficient  considera- 
tion is  given  to  the  economic  side  of  the  diet  question  in  dealing  with 
poor  people.  The  physician  must  be  able  to  advise  as  to  the  foods 
which  have  a  high  food  value,  are  palatable,  and  have  a  low  cost. 

An  effort  should  be  made  to  have  the  food  taken  in  as  concentrated 
a  form  as  possible,  as  individuals  with  weak  stomachs  may  have  diges- 
tive troubles  started  if  the  bulk  is  too  great.  This  is  not  so  important 
in  working  people,  as  their  diet  is  ordinarily  rather  bulky.  In  fact, 
sometimes  if  people  accustomed  to  bulky  diets  are  given  the  same  food 
value  in  more  concentrated  form  they  complain  that  it  does  not  satisfy 
their  hunger. 
26 


402  DIET  IX  DISEASE 

It  is  exceedingly  important  to  keep  in  mind  the  individual  require- 
ments, and  some  patients  undoubtedly  do  better  on  a  diet  containing 
smaller  amounts  of  protein.  The  excreting  powers,  the  patient's  gen- 
eral appearance  and  condition,  and  other  points  to  be  appreciated 
only  by  actual  experience,  are  of  great  value  in  regulating  the  diet 
of  the  tuberculous  patient.  A  diminution  of  the  amount  of  food 
taken  may  be  necessitated  by  too  rapid  gain  in  weight,  or  by  too  much 
nausea  and  vomiting,  or  by  other  evidences  of  gastro-intestinal  dis- 
turbance. A  fat  indigestion  calls  for  a  reduction  in  the  amount  of 
fat  taken,  and  the  increase  in  the  dietary  in  those  cases  may  often  be 
made  up  by  a  corresponding  increase  in  the  carbohydrates.  A  reduc- 
tion in  the  amount  of  carbohydrates  may  be  indicated  where  there  is 
intestinal  indigestion. 

A  meat-free  diet  is  sometimes  advised,  and  it  would  seem  that  in 
early  cases,  with  powerful  digestion,  it  may  be  substituted  for  the 
ordinary  diet.  Its  only  advantage,  however,  is  its  cheapness.  When 
the  appetite  and  digestion  are  poor,  as  concentrated  a  diet  as  possible 
is  advised,  as  the  meat-free  diet  is  too  bulky  and  liable  to  cause  gastric 
and  intestinal  indigestion,  and  this,  in  turn,  a  lessened  absorption. 
Vegetables  are  more  difficult  to  render  palatable  and  require  more 
skill  in  their  preparation,  a  point  often  overlooked  by  vegetarian 
enthusiasts. 

The  nutrition  of  the  patient  is  a  reliable  guide  as  to  the  progress 
of  the  disease.  If  he  is  taking  sufficient  nutritious  food,  is  digesting 
it,  and  is  gaining  in  weight,  the  prognosis  is  good.  If  the  reverse  is 
the  case,  the  prognosis  is  bad.  A  persistent  inability  to  digest  food 
is  always  an  unfavorable  symptom.  Care  should  be  taken  to  avoid 
disturbing  the  stomach  by  the  use  of  nauseating  drugs.  Patients  are 
too  frequently  dosed  excessively  with  creosote,  cod-liver  oil,  cough 
mixtures,  and  hypophosphites,  while  milk  and  eggs  are  not  given  often 
enough  or  only  in  insufficient  quantities. 

Irritability  of  the  stomach  should  receive  early  and  the  most  careful 
consideration.  It  is  usually  due  to  fever,  anemia,  the  swallowing  of 
sputum,  or  improper  food  or  drugs.  If  due  to  fever,  care  in  selecting 
the  diet,  as  will  be  described  hereafter,  should  be  exercised.  When 
there  is  marked  anemia,  fresh  air,  sunshine,  good  food,  massage,  and 
iron  in  an  easily  assimilable  form  are  helpful.  In  all  cases  the  patient 
should  be  instructed  not  to  swallow  the  sputum,  as  irritability  of  the 
stomach  with  vomiting  is  almost  certain  to  follow  sooner  or  later. 
He  should  be  questioned  closely  regarding  the  food  and  drugs  he  is 
taking.  One  should  be  certain  that  he  is  not  taking  a  patent  medicine 
in  addition  to  what  has  been  prescribed  for  him.  ' '  Quick  cures ' '  are 
always  attractive,  and  are  often  indulged  in  secretly,  to  the  great 
detriment  of  the  patient.  A  suspension  of  all  drugs  from  time  to 
time  will  do  much  to  relieve  the  overdosed  stomach.     In  some  indi- 


THE  FEEDING  IN  INFECTIOUS  DISEASES  403 

viduals  irritability  and  nausea  may  be  brought  on  by  the  too  con- 
tinuous administration  of  any  one  drug. 

The  appetite,  since  it  is  generally  poor  and  capricious,  is  not  a 
good  guide  as  to  the  amount  of  food  to  be  taken.  In  most  cases  more 
food  can  be  digested  than  the  appetite  demands.  While  this  is  so, 
the  desires  of  the  patient  should,  nevertheless,  be  consulted  so  far  as 
possible,  and  more  good  can  generally  be  accomplished  by  humoring 
the  patient's  reasonable  demands  than  by  combating  them.  The 
character  of  each  patient  should  be  studied,  and  in  this  condition 
particularly  tact  plays  an  important  role.  A  nurse  or  a  physician 
with  natural  tact  and  sympathy  will  often  manage  to  get  sufficient 
food  into  an  intractable  or  capricious  patient  where  skill  and  want 
of  tact  would  fail  completely. 

The  food  should  be  ready  at  the  time  the  meal  is  served,  and  the 
service  should  be  prompt,  so  that  the  patient  is  not  tired  out  waiting 
between  courses,  and  also,  that  he  does  not  lose  his  appetite  and  pa- 
tience. The  plate  should  not  be  piled  full  of  food  which  the  patient 
is  expected  to  eat,  as  smaller  and  repeated  helpings  have  been  found 
to  be  better.  Congenial  table  companions  are  a  great  stimulus  to 
eating,  and  manj^  patients  eat  fairly  well  if  seated  with  others  who 
are  cheerful  and  have  good  appetites. 

Other  factors  to  be  considered  are  the  nationality  and  the  usual 
mode  of  life  of  the  patient.  Many  of  the  diet-lists  intended  for 
tuberculous  patients  are  taken  from  the  vi'orks  of  German  writers.  A 
German  or  a  German-American  might  thrive  upon  these,  whereas  an 
Englishman,  a  Frenchman,  or  an  American  would  find  it  difficult  to 
take  some  of  the  articles  advised. 

In  the  choice  and  preparation  of  food  the  utmost  care  should  be 
exercised.  Detweiler's  saying,  "My  kitchen  is  my  pharmacy,"  holds 
in  these  cases.  The  food  should  be  prepared  simply,  and  yet  should 
be  varied  and  made  as  tempting  as  possible. 

The  stomach  and  intestine  should  be  watched,  and  constipation 
promptly  relieved.  Patients  who  are  taking  large  quantities  of  food 
and  resting  much  of  the  time  are  apt  to  be  costive.  Sugars  and 
starches  are  rarely  well  borne.  This  may  be  due  to  the  presence  of 
catarrhal  conditions  of  the  bowel,  but  may  also  be  true  even  when 
catarrh  is  not  present.  Young,  growing  girls  often  crave  sweets,  and 
when  this  craving  is  indulged  in  to  excess,  the  stomach  and  digestion 
become  disordered. 

While  sufficient  food  should  be  given,  an  excess  is  injurious,  and 
each  patient  should  be  watched  carefully.  Not  more  should  be  given 
at  one  time  than  the  patient  can  digest  with  ease.  Bardswell  and 
Chapman,  in  their  studies  on  metabolism  in  tuberculosis,  found  that 
some  patients  who  were  taking  very  large  quantities  of  food  and 
were  gaining  in  weight  were  excreting  excessive  amounts  of  urea — over 


404  DIET  IN  DISEASE 

900  grains  daily.  These  patients  generally  maintained  their  normal 
weight,  and  the  disease  appeared  to  be  quiescent.  For  economic 
reasons  they  were  obliged  to  reduce  the  diet  of  the  patients,  and 
found  that,  instead  of  producing  disastrous  results,  a  gain  in  weight 
and  general  improvement  followed.  These  patients,  of  course,  were 
being  somewhat  overfed. 

Rest  is  important,  and  the  patient  should  be  instructed  to  rest 
before  and  after  meals ;  if  he  is  not  receiving  the  combined  rest  and 
diet  cure,  to  be  spoken  of  later,  he  should  lie  down  at  least  half  an 
hour  before  and  after  meals. 

Coughing  is  sometimes  excited  by  the  taking  of  food.  If  this  is 
due  to  laryngeal  involvement,  it  should  be  managed  according  to 
directions  given  under  Diseases  of  the  Larynx.  When  it  is  due  to 
the  pressure  of  an  overfilled  stomach,  the  meals  may  be  smaller  and 
closer  together,  Gavage  or  feeding  by  means  of  a  soft-rubber  tube 
may  be  employed  in  those  cases  that  vomit  everything  they  eat  because 
swallowing  brings  on  a  spasmodic  cough. 

The  care  of  the  mouth  is  of  great  importance.  It  is  well  to  rinse 
the  mouth  before  and  after  eating.  The  teeth  also  should  be  kept 
scrupulously  clean.  Knopf  advises  the  use  of  the  following  mixture 
after  meals : 

^     Essence  of  peppermint    Tri,x. 

Oil  of  wintergreen   n\,xv. 

Thymol    gr.xv. 

Benzoic   acid    3iij. 

Tincture  of  eucalyptus    5ij. 

Alcohol    3XV. 

M.     Half  a  teaspoonful  in  a  glass  of  water  to  be  used  aa  a  mouth-wash. 

Foods  to  be  Used  by  Tuberculous  Patients. — Milk. — This  is  one 
of  the  most  important  articles  of  diet  for  the  tuberculous  patient. 
Unless  some  special  reason  exists,  milk  should  always  form  a  part  of 
the  diet.  It  may  be  taken  with  the  meals  or  be  given  between  the 
intervals  of  feeding.  It  is  of  the  utmost  importance  that  the  milk  be 
sipped  slowly,  and  not  swallowed  quickly  in  large  quantities.  The 
milk  may  be  taken  plain,  or  may  be  modified  in  various  ways.  Lime- 
water  may  be  added,  with  or  without  the  addition  of  cream ;  car- 
bonated water  may  be  mixed  with  it,  or  the  milk  may  be  peptonized. 
Buttermilk  or  kumiss  may  be  taken  if  desired. 

Eggs,  when  they  can  be  taken  in  sufficient  quantities,  are  also  of 
great  value.  In  certain  cases  they  are  not  well  borne.  Very  lightly 
coddled  eggs  are  perhaps  best,  but  soft  boiled,  poached  eggs,  or  an 
omelet  may  be  used  for  a  change.  Hard  boiled  eggs,  if  finely  divided, 
may  be  used.  Whole  raw  eggs  shaken  up  in  milk  or  orange  juice  may 
be  used  to  advantage.  There  is  some  question  as  to  the  value  of  raw 
white  of  egg,  as  it  is  difficult  of  digestion  and  not  so  completely 
utilized  as  if  slightly  cooked. 


TEE  FEEDING  IN  INFECTIOUS  DISEASES  405 

Meat. — Meat  of  all  kinds,  if  properly  prepared,  may  be  eaten;  but 
"high"  game,  highly  seasoned  dishes,  and  twice-cooked  meats  should 
be  avoided.  Beef  and  mutton  are  the  most  suitable  varieties.  Raw 
meats,  especially  raw  beef,  have  been  highly  extolled  by  French 
writers.  The  experimental  work  of  Eichet  and  Hericourt  on  dogs, 
tending  to  show  the  value  of  raw  meat,  has  been  much  criticised. 
Cornil  and  Chantemesse  recently  contributed  to  this  subject  by  their 
experiments  on  dogs.  Placed  under  similar  conditions,  some  of  the 
animals  were  fed  on  raw  meat  and  others  on  cooked,  and  both  series 
were  inoculated  with  virulent  tubercle  bacilli.  The  dogs  fed  on  cooked 
meat  all  died  in  a  short  time  of  tuberculosis,  while  those  fed  on  raw 
meat  lived.  Some  of  the  animals,  at  the  time  in  apparent  good  health, 
were  killed  and  showed  tuberculous  deposits.  Others  lived  in  ap- 
parent good  health,  and  on  being  killed  a  year  later  showed  tuberculous 
deposits  in  a  condition  of  healing. 

Galbraith  has  recently  shown  that  the  exhibition  of  raw  meat  is 
followed  by  a  marked  increase  of  nitrogen  retention,  provided  the 
heat  value  and  nitrogen  of  the  diet  exceeded  the  actual  requirements 
of  the  individual  per  kilo  of  body  weight.  He  also  found  that  there 
was  an  improvement  in  the  intestinal  metabolism,  and  this  improve- 
ment lasts  some  time  after  the  return  to  the  use  of  cooked  meat. 
In  Galbraith 's  patients  there  was  a  rapid  increase  in  the  hemoglobin, 
and  the  digestive  leukocytes  was  remarkably  increased. 

Grancher  suggests  that  for  tuberculous  patients  the  raw  meat  be 
given  in  the  form  of  a  finely  divided  pulp.  This  is  prepared  by 
scraping  the  meat  with  a  knife,  which  will  result  in  a  mass  of  shredded 
meat-fiber.  This  is  placed  in  a  mortar  and  pounded  and  rubbed  with 
a  pestle  until  quite  smooth.  It  is  then  pressed  gently  through  a 
sieve  to  remove  any  larger  particles.  This  raw  meat-pulp  is  very 
easily  digested  and  highly  nutritious.  It  may  be  given  in  various 
ways,  as  spread  on  sandwiches  or  given  in  milk  or  in  warm  bouillon. 
It  may  be  mixed  with  purees  of  various  kinds  or  with  vegetables,  or, 
in  the  case  of  children,  with  small  quantities  of  preserves.  It  may 
be  rolled  into  balls  and  so  easily  swallowed,  or  it  may  be  served  with 
an  egg,  with  anchovies,  or  with  pickled  herring. 

Meat-juice  is  also  of  great  value.  This  may  be  prepared  according 
to  any  of  the  recipes  given  in  the  Appendix,  or  the  juice  may  be 
expressed  from  beef  by  means  of  a  meat-press.  Good  round  steak 
should  be  very  slightly  broiled,  cut  into  small  cubes,  and  the  juice 
pressed  out.  With  a  good  press  about  eight  ounces  of  juice  can  be 
extracted  from  a  pound  of  meat.  This  should  be  seasoned  and  heated 
by  placing  the  vessel  containing  it  in  warm  water.  Care  should  be 
taken  not  to  heat  it  too  thoroughly,  or  the  albumin  will  coagulate 
and  the  juice  be  spoiled.  Freshly  prepared  beef-juice  is  always  pre- 
ferable, but  when  this  can  not  be  obtained,  liquid  beef  peptonoids, 
predigested  beef,  or  Mosquera  Beef  Meal  may  be  employed. 


406  DIE'^  I^'  DISEASE 

J.  C.  Roiix  and  Josias  have  used  the  raw-meat  cure  in  children  with 
good  results.     No  cooked  meat  was  allowed  these  patients. 

For  patients  who  can  not  or  will  not  take  raw  beef,  very  rare  steak, 
roast-beef,  or  beef  soup  should  be  prescribed. 

Fish. — Fresh  fish,  boiled,  broiled,  or  baked,  may  be  allowed.  Both 
oysters  and  clams  from  which  the  hard  portion  has  been  removed  may 
be  eaten,  preferably  raw,  but  they  may  also  be  given  stewed,  roasted, 
or  broiled. 

Cereals. — Where  these  can  be  digested,  they  are  of  value.  In  the 
early  stages  of  the  disease  they  serve  not  only  as  nutriment,  but  also 
aid  in  regulating  the  bowels,  and  are  usually  easily  digested.  If  there 
is  constipation,  they  are  of  especial  value.  Oatmeal,  wheaten  grits, 
cornmeal  mush,  and  rice  and  milk  are  the  most  suitable  forms. 

Vegetables. — Any  of  the  easily  digested  vegetables  may  be  allowed. 
They  should  be  steamed  or  cooked  with  as  little  water  as  possible,  to 
avoid  dissolving  out  the  salts,  which,  together  with  much  of  the  nutri- 
ment, are  thrown  away  with  the  water. 

Bread. — Wheat  or  rye  bread,  or  mixtures  of  both,  may  be  used. 
Zwieback  is  of  great  value.  All  hot  breads,  pastry,  and  cakes  should 
be  avoided. 

Fruit. — All  fresh  and  perfectly  ripe  fruit  may  be  allowed  in  modera- 
tion. It  should  be  taken  the  first  thing  in  the  morning  or  as  a  dessert. 
Baked  apples  and  oranges  are  well  borne  and  useful,  and  grapes, 
peaches,  pears,  and  other  fruit  in  season  may  be  allowed. 

Fats. — In  tuberculosis,  when  fats  and  oils  can  be  taken  and  ab- 
sorbed, the  prognosis  is  always  much  better  than  when  these  can  not 
be  tolerated.  While  they  are  of  the  greatest  value  in  treatment,  care 
should  be  taken  not  to  disturb  the  patient 's  digestion  by  forcing  more 
fatty  foods  into  the  dietary  than  the  stomach  will  tolerate.  Most 
patients,  however,  soon  acquire  a  dislike  for  fats  of  all  kinds.  They 
are  best  given  in  the  form  of  cream  and  butter ;  the  yolks  of  eggs, 
crisp  fat  bacon,  and  olive  oil  are  also  useful.  Cod-liver  oil  is  really 
as  much  a  food  as  a  medicine.  Either  the  plain  oil  or  an  emulsion 
may  be  used,  and  the  doses  should  be  small  to  begin  with  and  gradually 
be  increased.  A  common  mistake  is  to  administer  the  oil  in  excessive 
quantities.  Only  perfectly  sweet  fresh  oil  is  to  be  used,  as  rancid  or 
stale  oil  may  disturb  the  digestion.  Its  use  should  be  discontinued 
from  time  to  time.  Children  bear  oil  better  than  do  adults.  If 
there  is  a  tendency  to  diarrhea,  fats  and  oils  must  be  used  with  cau- 
tion. 

Alcohol. — There  is  much  diversity  of  opinion  concerning  the  in- 
fluence of  alcohol  on  tuberculosis.  Three  views  have  been  expressed, 
and  each  has  its  supporters : 

1.  That  alcoholism  is  antagonistic  to  tuberculosis. 

2.  That  alcoholism  exerts  no  special  influence  on  the  individual  as 
regards  tuberculosis. 


THE  FEEDING  IN  INFECTIOUS  DISEASES  407 

3.  That  alcoholism  definitely  predisposes  to  tuberculosis. 

The  last  view  has  the  largest  number  of  supporters,  as  alcoholism 
probably  renders  the  body  more  susceptible  to  all  infections.  Osier 
has  stated  his  opinion  as  follows:  "It  was  formerly  thought  that 
alcohol  was  in  some  way  antagonistic  to  tuberculous  disease,  but  the 
observations  of  late  years  indicate  clearly  that  the  reverse  is  the  case, 
and  that  chronic  drinkers  are  much  more  liable  to  both  acute  and 
pulmonary  tuberculosis.  It  is  probably  altogether  a  question  of  al- 
tered tissue-soil,  the  alcohol  lowering  the  vitality  and  enabling  the 
bacilli  more  readily  to  develop  and  grow," 

Concerning  the  use  of  alcohol  in  the  treatment  of  tuberculosis,  it 
may  be  said  that,  except  in  the  last  stages  of  the  disease,  it  is  best 
avoided.  Nationality  and  habits,  however,  must  not  be  disregarded. 
To  those  habituated  to  the  use  of  a  glass  of  wine  or  beer  with  their 
dinner,  this  may  be  allowed.  The  quantity  taken  must  be  limited 
to  the  smallest  reasonable  allowance.  This  will  vary  with  each  in- 
dividual. 

Patients  who  are  gaining  in  weight  or  who  are  in  good  condition 
are  better  off  without  alcohol.  Those  who  are  going  down-hill,  may 
often  take  light  wine,  beer,  or  well-diluted  spirits  with  advantage. 
Of  the  last,  well-matured,  pure  whisky  is  the  best. 

Patients  with  high  fever  who  are  in  an  exhausted  condition  may  be 
given  alcohol  freely,  following  the  same  rules  as  were  laid  down  in 
the  general  consideration  of  fevers.  In  these  cases  alcohol  is  given 
as  a  food,  and  is,  as  a  rule,  very  well  borne.  In  these  advanced  cases 
pure  whisky  well  diluted  is  perhaps  the  best  form  of  alcoholic  stimu- 
lant, but  the  patient's  taste  may  be  consulted  in  this  respect. 

Other  Beverages. — The  usual  beverages  may  be  given  in  moderation. 
In  chronic  tuberculosis  cocoa  may  be  taken  night  and  morning  with 
good  effect.  Tea  or  coffee  may  be  allowed  in  small  quantities  unless 
they  produce  unfavorable  symptoms.  Milk  and  milk-punch,  butter- 
milk, lemonade,  or  orangeade  may  be  used,  and  malt  extracts  are 
often  of  benefit. 

Number  of  Meals. — Food  may  be  given  from  three  to  six  times 
daily.  On  rising,  milk  may  be  taken,  or,  if  desired,  a  cup  of  bouillon 
instead.  This  may  be  followed  by  breakfast,  and  about  the  middle 
of  the  morning  a  glass  of  milk,  egg-albumin,  beef-juice,  or  broth  may 
be  given  with  a  cracker  or  a  piece  of  toast. 

A  midday  dinner  should  be  the  rule,  and  during  the  middle  of  the 
afternoon  a  light  lunch  of  scraped  beef,  milk,  or  some  similar  food 
may  be  given. 

Supper  may  be  taken  at  a  convenient  evening  hour,  and  before 
going  to  bed  a  glass  of  milk  may  be  drunk.  If  desired  or  if  deemed 
necessary,  a  small  amount  of  liquid  nourishment  may  be  taken  during 
the  night  if  the  patient  awakens.  As  a  rule,  however,  it  is  well  to 
give  the  stomach  a  full  night's  rest.     In  severe  eases,  where  only 


408  DIET  IN  DISEASE 

small  quantities  of  liquid  or  semisolid  food  are  taken,  the  intervals 
should  be  shortened  to  every  two  or  three  hours. 

Feeding  Advanced  Cases. — In  advanced  cases  patients  may  gen- 
erally be  permitted  to  select  their  diet.  These  patients  can  often  eat 
hearty  meals  with  a  relish  and  apparently  digest  them  without  diffi- 
culty. As  a  rule,  their  diet  must  be  light,  liquid,  or  semisolid.  The 
same  principles  may  be  applied  here  as  in  feeding  fever  cases,  with 
the  exception  that  the  patient's  desires  should,  as  far  as  possible,  be 
gratified. 

Phthisis  Cures. — Various  diet  cures  have  been  advocated  for  the 
relief  of  phthisis,  and  these  are  referred  to  under  the  head  of  Diet 
Cures.  The  benefit  which  follows  their  use  is  due  largely  to  the  fresh 
air  and  abundance  of  food  they  prescribe. 

If  the  patient  is  well-to-do  and  can  afford  a  liberal  dietary  there  is 
little  difficulty  in  constructing  a  suitable  diet  list  giving  approximately 
the  proper  amounts  of  protein,  carbohydrates,  and  fats  with  a  total 
number  of  calories  sufficiently  large  to  give  the  best  results.  The 
exact  amount  of  food  required  is  most  easily  determined  by  ordering 
a  diet  which  will  contain  about  30  per  cent,  more  protein  food  than 
would  be  required  by  the  patient  ordinarily  if  not  working  and  in- 
creasing the  carbohydrates.  This  can  easily  be  done  by  adding  3 
or  4  pints  of  milk  or  1  quart  of  milk  and  2  to  4  eggs  to  just  about 
such  a  diet  of  plain  food  as  the  majority  of  well-to-do  people  con- 
sume. 

This  may  be  given  as  follows: 

If  desired  a  glass  of  milk  may  be  given  early  before  breakfast 
before  the  patient  has  got  out  of  bed. 

Breakfast. — A  glass  of  milk ;  this  may  be  flavored  with  tea  or  coffee 
and  taken  from  a  coffee  cup,  if  desired.  If  the  patient  wishes  it  an 
orange  or  a  small  amount  of  some  other  fruit,  an  ordinary  helping 
of  oatmeal,  2  soft-boiled  or  poached  eggs,  2  slices  of  toast  or  bread, 
and  14  ounce  of  butter.  A  small  piece  of  bacon  may  be  taken  with 
the  eggs  if  desired,  or  an  ordinary  helping  of  meat  or  fish  may  be 
substituted.  In  the  middle  of  the  morning,  at  10.30  or  11.30,  a  glass 
of  milk. 

Luncheon. — A  glass  of  milk,  a  helping  of  fish  or  a  chop  or  a  piece 
of  steak  or  some  meat  entree,  a  slice  of  bread  or  toast  or  a  roll,  I/2 
ounce  of  butter,  a  potato  or  a  helping  of  rice  or  hominy  or  the 
equivalent.  A  green  vegetable,  as  spinach  or  a  lettuce  or  tomato 
salad,  and  a  dessert  of  junket,  bread  pudding,  baked  custard,  or  some 
similar  nutritious  dish. 

In  place  of  afternoon  tea,  a  glass  of  milk  with  a  few  slices  of  bread 
and  butter. 

Dinner. — A  glass  of  milk,  a  small  amount  of  soup  if  desired,  and 
if  it  does  not  interfere  with  the  appetite,  an  entree  if  desired,  a  good 
helping  of  some  substantial  plain  meat,  as  roast  beef,  mutton,  or 


hydrates.    Calories. 

Grams. 

Grams. 

70 

87 

6 

32 

8 

22 

10 

2 

88 

4 

40 

30 

ie 

50 

1 

7 

THE  FEEDING  IN  INFECTIOUS  DISEASES  409 

lamb,  or  chicken,  guinea-hen  or  turkey,  potatoes,  or  a  farinaceous 
vegetable  and  a  green  vegetable,  a  salad  if  desired,  dessert,  and  a 
small  piece  of  cheese. 

At  Bedtime. — A  glass  of  milk. 

The  above  works  out  approximately  as  follows:  . 

Food.  Protein.  Fat.  Carbo- 

Grams. 

Milk,  3  pints   57 

Cream,  1  ounce   1 

Butter,  li  ounces .... 

Eggs,  2    12 

Meat,  6  ounces    44 

Fish,  4  ounces   20 

Bread,  6  ounces    16 

Cereal,  2  ounces    8 

Potatoes  or  vegetables,  5  ounces   1 

Desserts,   4  ounces    9 

Green  vegetables,        1 

Fruit,            1 1 

Soups,  etc.        j  

169      171      302     3480.4 

The  milk  taken  at  meal  time  should  be  drunk  at  the  end  of  the  meal 
and  not  at  the  beginning,  so  as  not  to  interfere  with  the  appetite. 

The  dinner  may  be  taken  in  the  middle  of  the  day  if  desired,  and 
the  rather  lighter  meal  taken  as  supper  in  the  evening. 

Diets  for  the  poorer  classes  of  the  people  should  be  so  arranged  as 
to  be  more  or  less  like  the  diet  to  which  they  are  accustomed,  both 
in  composition  and  price.  This  means  that  the  dietary  is  more  bulky, 
contains  more  carbohydrates  and  less  fat.  The  additional  protein 
and  carbohydrate  and  fat  can  be  conveniently  and  cheaply  added  in 
a  quart  of.  milk,  meat,  beans,  peas,  or  lentils,  and  butter.  Where 
price  is  a  very  great  item  skim  milk  may  be  used  in  part  or  entirely 
and  oleomargarin  substituted  for  the  butter.  Beans,  hominy,  corn- 
meal,  lentils,  dried  peas,  and  similar  articles  of  diet  may  be  used  in 
large  quantities  and  the  cheaper  cuts  of  meat  substituted.  There  is 
not  always  any  real  economy  in  cheaper  cuts  of  meat,  as  some  of  them 
contain  comparatively  little  nutriment.  In  cities  where  there  are 
markets,  by  purchasing  just  before  the  market  closes,  odds  and  ends 
of  various  cuts  may  often  be  bought  at  very  low  prices  and  to  greater 
advantage  from  the  standpoint  of  food  value  than  cheaper  cuts. 

The  diet  in  sanitariums  and  hospitals  for  consumptives  is  carried 
on  in  the  same  manner  as  in  private  practice.  The  following  is  from 
Bardswell  and  Campbell,  and  gives  a  very  good  standard  in  the  present 
state  of  our  knowledge  of  the  subject.  Individual  variations  must  be 
made  just  as  in  private  practice : 


410 


DIET  IN  DISEASE 


Diet  for  Consumptives. 
(Standard  diets  in  use  at  the  King  Edward  VII.  Sanatorium.) 


7.30 

A.  M. 


12 
noon. 
1.15 
p.  M. 


4.30 

P.  M. 


7.15 

P.  M. 


Men. 


9.30 


MUk 

Breakfast  : 
Porridge  (with  milk)  .  . 

Egg 

Meat  (A),  etc 

Bread 

Butter 

Tea,  coffee,  marmalade 

etc 

Milk 

Luncheon : 

Meat  (B) 

Pudding  (suet  or  milk) 

Bread 

Bidter 

MUk 

Potatoes  and  vegetables 

or  salad 

Stewed  fruit,  jam,  etc.  . 
Cheese  and  biscuits  .  .  . 

Tea  (optional) : 

Tea,  bread,  and  butter, 
sandwiches  or  cake  .   , 

Dinner : 

Soup  or  fish  (optional). 

ifeat  (C) 

Pudding  (milk  or  suet) 

Bread 

Bidter 

Milk 

Potatoes  and  vegetables  . 
Stewed  fruit,  jam,  etc.  . 
Cheese  and  biscuits  .  .   . 

Milk 


pint. 


i  pint. 
1  (4  days  a 
week). 
2oz. 
2  oz. 
ioz. 

q.  s. 
i  pint. 


3  oz. 
5  oz. 
2  oz. 
i  oz. 
i  pint. 

q.  s. 
q.  s. 
q.  s. 


q.  s. 


3  oz. 
5  oz. 
2  oz. 
i  oz. 
I  pint, 
q.  s. 
q.  8. 
q.  s. 

h  pint. 


Women. 


MUk 

Breakfast  : 
Porridge  (with  milk)    . 
Egg 

Meat(Ji.),etc 

Bread 

Butter 

Tea,  coffee,  marmalade, 

jam,  etc 

Milk 

Luncheon : 

Meat  (B) 

Pudding  (suet  or  milk) 

Bread 

Butter 

MUk 

Potatoes  and  vegetables 

or  salad 

Stewed  fruit,  jam,  etc.  . 
Cheese  and  biscuits  .   .   . 

Tea  (optional) : 

Tea,  bread,  and  butter, 
sandwiches  or  cake  .  . 

Dinner : 

Soup  or  fish  (optional). 

Meat{C) 

Pudding  (milk  or  suet) 

Bread 

Butter 

MUk 

Potatoes  and  vegetables  . 
Stewed  fruit,  jam,  etc.  .  . 
Cheese  and  biscuits  .  .   . 

Milk 


i  pint. 


i  pint. 
1  (4  days  a 
week), 
lioz. 
li  oz. 
i  oz. 


pint. 


2^  oz. 
3  oz. 
lioz. 
I  oz. 
i  pint. 

q.  s. 
q.  s. 
q.  s. 


q.  s. 


2i  OB. 
3  oz. 
IJoz. 
\  oz. 
i  pint, 
q.  B. 
q.  s. 
q.  8. 

i  pint. 


N.  B. — The  weights  given  are  the  minimum  quantities  which  pa- 
tients are  prescribed;  second  helpings  of  meat,  pudding,  and  butter 
are  allowed  if  asked  for. 

Milk  is  not  given  both  at  7.30  a.  m.  and  12  noon,  but  it  is  left  to 
the  patient's  choice  at  which  time  it  is  taken. 

Meat  (A). — At  breakfast,  on  different  days  of  the  week,  one  of  the 
following  is  provided: 

Bacon,  ham,  fish,  tongue,  or  sausage. 

Meat  (B). — At  lunch,  consists  of  one  of  the  following: 

Koast  or  boiled  beef,  hot  or  cold. 

Roast  or  boiled  mutton,  hot  or  cold. 

Beefsteak  and  kidney  pudding,  stewed  steak  or  Irish  stew,  or  liver 
and  bacon. 

Chicken,  roast  lamb,  veal,  or  pork  occasionally. 

Meat  ( C ) . — At  dinner,  consists  of  one  of  the  following : 

Hot  roast  or  boiled  beef,  hot  roast  or  boiled  mutton,  hot  roast 
lamb. 


TEE  FEEDING  IN  INFECTIOUS  DISEASES  411 

The  compulsory  diets,  which  are  printed  in  italics,  and  which  are 
prescribed  in  weighed  and  measured  amount,  as  shown  in  the  table, 
give  diets  of  the  following  nutritive  values : 

Men. — Protein,  144  gm. ;  fat,  160  gm. ;  carbohydrate,  270  gm. ; 
calories,  3186, 

Women. — Protein,  126  gm. ;  fat,  160  gm. ;  carbohydrate,  220  gm. ; 
calories,  2814. 

Gastric  Irritability. — Gastric  irritability  is  a  troublesome  symptom 
in  many  eases  of  tuberculosis.  Care  in  avoiding  nauseous  drugs  and 
preparations  will  have  much  to  do  in  preventing  it.  The  patient  must 
also  be  enjoined  strictly  not  to  swallow  the  sputum.  If  the  attack 
is  severe,  the  patient  should  be  placed  on  a  liquid  diet,  consisting 
chiefly  of  milk  in  some  form,  diluted  or  peptonized.  Buttermilk  and 
kumiss  are  valuable  in  this  condition  and  are  often  well  borne. 
Fresh  meat-juice  and  broths  may  be  allowed,  and  the  various  pepton- 
ized dishes  mentioned  in  the  Appendix  may  be  given  to  lend  variety 
to  the  diet.  Scraped  meat  mixed  with  milk  or  prepared  in  the  form 
of  small  balls  is  often  of  service.  The  predigested  liquid  beef  prepara- 
tions are  useful,  and  may  be  given  diluted  with  water.  Panopepton 
poured  over  crushed  ice  is  sometimes  retained  when  everything  else 
is  rejected. 

Alcohol  may  be  used  in  the  later  stage  of  the  disease  or  when  the 
patient  is  very  weak.  Old  brandy  mixed  with  a  small  quantity  of  a 
cold  carbonated  water  or  teaspoonful  doses  of  iced  champagne  are 
advised  in  the  very  serious  cases.  Larger  doses  may  be  given  in  the 
less  severe  cases. 

Food  and  drink  should  be  given  in  small  quantities  at  short  in- 
tervals— one  to  four  ounces  every  two  or  three  hours,  or  twice  as 
much  at  longer  intervals.  The  quantity  taken  should  be  measured 
carefully  and  recorded,  as  otherwise  the  patient  may  receive  an  in- 
sufficient diet  or  be  given  a  superabundance.  In  severe  cases  washing 
out  the  stomach  gives  more  relief  than  any  other  procedure.  In  less 
severe  cases  a  glass  of  hot  water  with  or  without  sodium  bicarbonate 
may  be  taken  on  rising,  and  at  least  half  an  hour  before  eating,  or 
preferably  an  hour  before. 

If  no  food  is  retained,  forced  feeding  by  means  of  a  stomach-tube 
may  be  tried.  This  is  known  as  Debove's  method.  Large  quantities 
— 8  to  16  ounces — may  sometimes  be  retained  when  given  by  the  tube 
that,  if  swallowed,  would  be  rejected  at  once.  If  the  severe  form  of 
irritability  persists,  rectal  feeding  may  be  resorted  to. 

Fever. — If  there  is  fever,  the  question  of  feeding  the  patient  should 
be  carefully  considered.  If  there  is  much  irritability  of  the  stomach, 
the  general  rules  for  feeding  fever  patients  may  be  followed.  If 
digestion  is  not  disturbed  and  the  appetite  is  good,  the  patient  may 
be  allowed  a  light  diet,  of  which  milk  should  form  a  large  part;  as  a 
rule,  it  is  best  given  cold.     The  usual  liquid  food  may  also  be  allowed. 


412  DIET  IN  DISEASE 

Soups,  white  meat  of  chicken,  raw  or  rare  roast-beef,  or  underdone 
mutton  are  indicated.  Boiled,  broiled,  or  baked  fish  and  oysters  and 
the  more  easily  digested  vegetables  are  permissible.  The  patient's 
surroundings  have  considerable  influence  on  his  appetite,  and  when 
possible,  he  should  take  his  meals  while  reclining  on  a  porch  or  in  a 
sun-parlor,  amid  perfect  quiet.  The  excitement  and  fatigue  of  a  meal 
in  the  dining-room  are  best  avoided. 

//  solid  food  does  not  agree,  the  patient  should  be  placed  on  a  liquid 
diet.  Generally,  however,  a  tuberculous  patient  with  fever  will  do 
remarkably  well  on  a  general  diet.  Milk,  lemonade,  and  similar 
preparations  are  useful,  recipes  for  which  will  be  found  in  the  Ap- 
pendix. 

The  diet  for  the  more  advanced  cases  has  been  indicated. 

Forced  Feeding  (Suralimentation). — Debove  discovered  accident- 
ally that  food  introduced  by  means  of  a  stomach-tube  was  retained 
when,  if  taken  by  the  mouth,  it  would  be  rejected.  He  therefore 
turned  his  attention  to  the  treatment  of  tuberculous  patients  by  means 
of  this  method,  and  met  with  a  measurable  success.  This  form  of 
treatment  is  especially  applicable  in  those  cases  where  there  are  an 
irritable  stomach  and  no  appetite. 

Food  is  introduced  into  the  stomach  by  the  tube  at  regular  inter- 
vals. Milk,  peptonized  or  diluted,  ground-meat  mixtures,  eggs  and 
milk,  albumin-water,  beef-juice,  predigested  beef  preparations,  and 
similar  liquid  foods  may  be  utilized  for  this  purpose. 

When,  during  fever,  the  patient's  appetite  and  will-power  are  equal 
to  it,  feeding  may  be  conducted  in  the  usual  way,  without  the  tube. 
Moderate  quantities  of  easily  digested  food  may  be  given  at  frequent 
intervals.  Two  or  three  rather  substantial  meals  form  the  basis  of 
the  diet,  while  on  rising,  at  bedtime,  and  during  the  intervals  be- 
tween meals  liquid  food  is  to  be  ordered.  Under  this  method  of 
treatment  certain  cases  gain  very  rapidly  and  recover  their  usual 
weight  in  a  short  time.  As  soon  as  the  customary  weight  of  the  pa- 
tient is  reached,  it  is  well  to  diminish  the  quantity  of  food  given,  so 
as  to  avoid  the  effects  of  overfeeding,  which  show  themselves  in  a 
coated  tongue,  a  heavy  breath,  torpidity,  and  the  train  of  symptoms 
popularly  known  as  biliousness.  Should  these  symptoms  arise,  a 
saline  or  small  doses  of  calomel,  together  with  a  reduction  in  the 
amount  of  food  given,  will  give  prompt  relief.  Gastric  catarrh  and 
fever  are  contraindications  to  suralimentation. 

DIET  IN  DISEASES  OF  THE  STOMACH 

In  diseases  of  the  stomach  the  selection  of  a  proper  diet  is  often 
of  more  importance  than  the  choice  of  drugs.  No  absolute  dietetic 
regulations  can  be  formulated  in  this  class  of  diseases,  but  it  is  im- 
portant to  regulate  the  food  in  conformity  with  the  particular  disease 
with  which  the  patient  is  affected,  and  also  to  consider  the  individual 


DIET  IN  DISEASES  OF  THE  STOMACH  413 

tastes  and  peculiarities  of  the  patient ;  even  in  the  regulation  of  a  diet 
in  an}'  special  disease  of  the  stomach  changes  are  often  rendered 
necessary;  these  must  be  made  gradually  and  according  to  the  pa- 
tient's power  to  digest  the  food. 

Food  is  said  to  be  easily  digestible  when  it  produces  no  gastro- 
intestinal discomfort,  is  passed  from  the  stomach  into  the  intestine 
at  a  normal  rate  of  speed,  and  is  easily  absorbed.  Under  normal  con- 
ditions the  digestibility  of  foods  is  easily  ascertained,  for  the  motor 
and  secretory  functions  of  the  stomach  being  normal,  the  effect  of  the 
food  upon  one  or  both  of  these  functions  can  readily  be  determined; 
in  the  various  gastric  disturbances,  however,  this  problem  is  more 
difficult,  for  here  there  may  be  a  motor  or  a  secretory  disturbance,  or 
both  functions  may  be  impaired.  In  determining  the  diet  for  a 
special  gastric  disturbance  two  points  must  be  borne  in  mind:  first, 
the  power  to  increase  the  nutrition  of  the  patient,  and,  secondly,  the 
necessity  of  giving  food  in  a  digestible  form,  so  as  to  lessen  the  work 
of  the  stomach.  Leube  has  devised  a  scale  of  the  various  articles  of 
food,  given  in  the  order  of  their  digestibility.  This  scale  forms  the 
basis  of  the  well-known  Leube  "ulcer  diet." 

Leube's  Diet  Scale.^ — Diet  I. — If  the  digestion  is  very  much  re- 
duced, the  following  articles  of  food  are  most  easily  digestible : 
bouillon,  meat  solution,  milk,  raw  or  soft-boiled  eggs. 

Diet  II. — Somewhat  less  digestible  than  Diet  I.  are  the  following 
articles  of  food:  boiled  calves '-brain,  boiled  thymus,  boiled  chicken 
and  pigeon.  The  different  forms  of  meat  are  enumerated  in  the  order 
of  their  digestibility.  Gruels,  and  in  the  evening  milk  mushes  made 
with  tapioca  and  white  of  egg,  may  also  be  placed  in  this  list.  The 
majority  of  patients  can  digest  boiled  calves'  feet  in  addition  to  the 
various  meat  foods  already  enumerated. 

Diet  III. — If  Diet  II.  is  well  borne.  Diet  III.  may  be  given.  This 
consists  in  adding  cooked  or  raw  beef  to  Diet  II.  Leube  gives  the 
following  method  of  preparing  beefsteak  and  believes  that  beef  cooked 
in  this  way  is  very  easily  digested :  The  meat  should  be  kept  for 
some  time,  and  is  then  scraped  with  a  dull  spoon ;  in  this  way  a  pulp 
is  obtained,  consisting  only  of  the  delicate  parts  of  the  muscle,  and 
not  containing  any  of  the  tough,  hard,  and  sinewy  portion.  This  pulp 
is  roasted  in  fresh  butter.  Raw  ham  is  also  to  be  recommended.  In 
addition  to  meat  a  small  quantity  of  mashed  potatoes  may  be  given, 
some  stale  wheat  bread,  and  small  amounts  of  coffee  or  tea  with  milk 
(cautiously). 

Diet  IV. — This  list  is  so  arranged  that  if  the  patient  can  digest  the 
articles  of  food  mentioned  under  this  head  for  some  time,  he  can  then 
begin  with  his  usually  accustomed  diet :  Roast  chicken,  roast  pigeon, 
venison,  partridge,  roast-beef — medium  to  raw  (particularly  cold), 
veal  (from  the  leg),  pickerel,  boiled  shad,  macaroni,  bouillon  with 
rice.     Small  quantities  of  wine  may  be  taken  one  to  two  hours  before 

1  Zeitschr.  f.  klin.  Med.,  vol.  vi.,  p.  191. 


414 


DIET  IX  DISEASE 


eating;  gravies  are  contraindicated.  Young  and  finely  chopped  spin- 
ach is  allowable ;  other  vegetables,  such  as  asparagus,  may  be  tried 
cautiously,  although  Leube  considers  this  a  rather  risky  procedure. 

Mean  lime  of  Ghymification. 


Articles  of  diet. 


Kice 

Sago 

Tapioca 

Barley 

Milk 

Milk 

Gelatin    ....... 

Pig's  feet,  soused    .    .    . 

Tripe,  soused 

Bi-ains,  animal  .  .  .  . 
Venison,  steak  .  .  .  . 
Spinal  marrow,  animal 
Turkey,  domesticated  . 
Turkey,  domesticated   . 

Turkey,  wild 

Goose,  wild 

Pig,  suckling 

Liver,  beef,  fresh  .    .    . 

Lamb,  fresh 

Chicken,  full-grown  .    . 

Eggs,  fresh 

Eggs,  fresh 

Eggs,  fresh 

Eggs,  fresh 

Eggs,  fresh  .  .  .  .  . 
Eggs,  whipped    .    .    .    . 

Custard 

Codfish,  cured  dry  .  .  . 
Trout,  salmon,  fresh  .  . 
Trout,  salmon,  fresh  .  . 
Bass,  striped,  fresh  .  . 
Flounder,  fresh  .    .    .    . 

Catfish,  fresh 

Salmon,  salted    .    .    .    . 

Oysters,  fresh 

Oysters,  fresh 

Oysters,  fresh 

Beef,  fresh,  lean,  rare  . 
Beef,  fresh,  lean,  dry     . 

Beefsteak 

Beefsteak 

Beefsteak 

Beef,  with  salt  only  .  . 
Beef,  with  mustard,  etc, 
Beef,  fresh,  lean     .    .    . 

Beef 

Beef 

Beef,  old,  hard,  salted  . 

Pork  steak 

Pork,  fat  and  lean  .  .  . 
Pork,  recently  salted 


In  stomach. 

In  vialj 

. 

How  prepared. 

Time. 

How  prepared. 

Time. 

h.    m. 

h.   n. 

Boiled     .    . 

1:00 

" 

1:45 

Boiled     .    . 

3:15 

(1 

2:00 

« 

3:20 

(I 

2:00 

(( 

2:00 

Boiled     .    . 

4:15 

Raw     .    . 

2:15 

Raw     .    .    . 

4:45 

Boiled     . 

(1 

2:30 
1:00 

BoUed     .    . 

4:45 

(f 

1:00 

(( 

1:45 

Boiled     .    . 

4:30 

Broiled   . 

1:35 

Boiled 

2:40 

Boiled     .    . 

5:25 

Roasted 

2:30 

Boiled 

2:2.5 

Roasted 

u 

2:18 
2:30 
2:30 

Broiled 

(1 

2:00 
2:30 

Cut  fine  .    . 

6:30 

Fricasseed  . 

2:45 

Hard  boiled 

3:30 

Hard  boiled 

8:00 

Soft  boiled 

3:00 

Soft  boiled  . 

6:30 

Fried  -    .    . 

3:30 

Roasted 

2:15 

Raw 

2:00 

Raw     .    .    . 

4:15 

11 

1:30 

Whipped    . 

4:00 

Baked . 

2:45 

Baked  .   .    . 

6:30 

Boiled 

2:00 

Boiled.    .    . 

5:00 

« 

1:30 

a 

3:30 

Fried  . 

Broiled 

3:00 

Fried  . 

3:30 

« 

3:30 

Boiled 

4:00 

Boiled      .    . 

7:45 

Raw     . 

2:55 

Raw,  entire 

7:30 

Roasted 

3:15 

Stewed 

3.30 

Stewed     .    . 

8:25 

Roasted 

3:00 

Roasted  .    . 

(( 

3:30 

a 

7:45 

Broiled 

3:00 

Masticated  . 
Cut  fine  .    . 

8:15 
8:00 

Raw     . 

(« 

8:15 

Boiled 

2:45 

9:30 

It 

3:30 

u 

Masticated  . 

<( 

Entire  piece. 

9:00 

Fried  . 

4:00 

Boiled 

4:15 

Broiled 

3:15 

Roasted 

5:15 

BoUed 

4:30 

Masticated  . 

6:30 

DIET  IN  DISEASES  OF  THE  STOMACH 


415 


Mean  Time  of  Chymification  (Continued). 


Articles  of  diet. 


Pork,  recently  salted     . 
Pork,  recently  salted 
Pork,  recently  salted 
Pork,  recently  salted     . 

Mutton,  fresh 

Mutton,  fresh 

Mutton,  fresh 

Mutton,  fresh 

Veal,  fresh 

Veal,  fresh 

Fowls,  domestic  .... 
Fowls,  domestic  .... 
Ducks,  domesticated  .    . 

Ducks,  wild 

Suet,  beef,  fresh  .... 

Suet,  mutton 

Butter 

Cream 

Cheese,  old,  strpng  .  . 
Cheese,  old,  strong  .  . 
Cheese,  new,  mild  .    .    . 

Oil,  olive 

Soup,    beef,    vegetables, 

bread 

Soup,  marrow  bones  .    .    .    . 

Soup,  bean  

Soup,  barley 

Soup,  mutton 

Green  corn  and  beans   .    .    . 

Chicken  soup 

Oyster  soup 

Hash,  meat  and  vegetables  . 

Sausage,  fresh 

Heart,  animal 

Tendon    

Tendon    

Cartilage 

Cartilage 

Aponeurosis 

Bone,  beef 's  solid 

Bone,  hog's  solid 

Beans,  pod 

Bread,  white,  fresh    .    .    .    . 

Bread,  corn 

Cake,  corn 

Cake,  sponge 

Dumpling,  apple 

Apples,  sour,  hard  .  .  .  . 
Apples,  sour,  mellow  .  .  . 
Apples,  sweet,  mellow  .  .  . 
Parsnips 


and 


In  Btomach. 


How  prepared.     Time 


Fried  . 
Broiled 
Eaw  . 
Stewed 
Koasted 

Broiled 

« 

Boiled 
Broiled 
Fried   . 
Boiled 
Roasted 


Boiled 
Melted 


Raw     . 


Boiled 


Warmed . 
Broiled 
Fried   .    . 
Boiled     . 


Boiled 
Boiled 


Boiled , 
Baked , 


Boiled 
Raw 


Boiled 


4:15 
3:15 
3:00 
3:00 
3:15 
3:00 

3:00 
4:00 
4:30 
4:00 
4:00 
4:00 
4:30 
5:30 
4:30 
3:30 


3.30 


4:00 
4:15 
3:00 
1:30 
3:30 
3:45 
3:00 
3:30 
2:30 
3:20 
4:00 
5:30 


4:15 

3:00 


2:30 
3:30 
3:15 
3:00 
2:30 
3:00 
2:50 
2:00 
1:30 
2:30 


In  vials. 


How  prepared. 


Raw 


Masticated 
Unmasticated 


Masticated 


Entire  piece. 
Divided  .    . 

Raw  .  .  . 
Masticated  . 
Entire  piece, 
Divided  .  . 
Raw     .    .    . 


Entire  piece. 
Masticated  . 
Entire  piece. 
Masticated  . 
Divided  .  . 
Boiled  .  . 
Entire  piece. 
Entire  piece. 

Masticated  . 


Broken    .    . 

Entire  piece. 
Masticated  . 

Mashed   .    . 


Time. 


h.    m. 


:30 


6:45 
8:30 


6:30 


12:00 
10:00 

25:30 

7:15 
18:00 

8:30 
60:00 


13:30 
12:45 
24:00 
10:00 
12:00 
6:30 
80:00 
80:00 

4:30 


6:16 

18:00 
8:30 
6:45 
6:45 


After  this  fourth  diet  the  patients  are  allowed  to  take  a  more  liberal 
diet,  but  the  increase  should  be  gradual.  They  should  refrain  from 
eating  vegetables,  salads,  preserves,  and  fruits  for  some  time;  and 


416 


DIET  IX  DISEASE 


Mean  Time  of  Chymijkaiion  (Continued). 


Articles  of  diet. 


Parsnips 

Parenips 

Carrot,  orange  .  .  . 
Carrot,  orange  .  .  . 
Carrot,  orange    .    .    . 

Beets 

Turnips,  flat  .... 
Potatoes,  Irish  .  .  . 
Potatoes,  Irish  .  .  . 
Potatoes,  Irish  .  .  . 
Potatoes,  Irish  .  .  . 
Cabbage,  head.  .  . 
Cabbage  with  vinegar 

Cabbage  

Peach,  mellow  .  .  . 
Peach,  mellow    .    .    . 


In  stomach. 


How  prepared.     Time. 


Boiled 
Raw     . 
Boiled 


Boiled . 


Roasted 
Baked. 
Raw  . 
Raw  . 
Boiled . 


3:15 


3:45 
3:30 
3:30 

2:30 
2:30 
2:30 
2:00 
4:30 


In  viala. 


How  prepared. 


Entire  piece, 
Entire  piece. 
Mashed  .  . 
Entire  piece, 
Raw        " 


Mashed    .    . 
Entire  piece. 


Masticated 
Shaved    . 
Boiled.    . 
Cut  small 
Mashed    . 


Time. 


h.  m. 
13:15 
18:00 
6:45 
12:30 
17:15 


8:30 
14:00 


12:30 
10:15 
20:00 
10:00 
6:00 


when  they  are  resumed,  a  baked  apple  is  the  first  of  these  larticles  to 
be  eaten. 

.  Beaumont's  Table. — This  shows  the  mean  time  of  digestion  of  the 
different  articles  of  diet — naturally,  in  the  stomach,  and  artificially, 
in  vials,  on  a  water-bath.  The  proportion  of  gastric  juice  to  aliment 
in  artificial  digestion  was  generally  calculated  at  one  ounce  of  the 
former  to  one  dram  of  the  latter,  the  bath  being  kept  as  close  to  the 
natural  temperature — 100°  F. — as  practicable,  with  frequent  agitation. 

"The  foregoing  table  was  computed  from  all  the  experiments  made 
upon  St.  ^Martin  since  1825,  taking  the  average  from  such  as  were 
generally  performed  under  the  naturally  healthy  condition  of  the 
stomach  and  with  ordinary  exercise." 

The  mean  times  of  artificial  chymification  have  been  taken  from 
such  experiments  as  were  generally  made  with  the  pure  gastric  juice, 
or  with  such  juice  as  was  too  slightly  vitiated  to  impair  its  solvent 
effect  in  any  essential  degree.  They  exhibit  the  average,  as  near  as 
practicable,  for  the  digestion  of  one  dram  of  alimentary  matter  in  one 
ounce  of  gastric  juice,  or  in  about  that  proportion,  taking  the  length 
of  time  the  food  and  gastric  juice  were  heated.  Exceptions,  however, 
must  be  made  for  the  bone,  oil,  cream,  and  one  or  two  other  articles, 
which  ch^-mify  much  slower  and  with  more  difficulty  than  the  less 
concentrated  aliments.  Several  experiments  where  the  methods  were 
the  same  and  the  results  were  similar  have  been  omitted. 

Penzoldt  has  devised  the  following  table  giving  the  digestibility  of 
food.  He  experimented  on  normal  cases,  achieving  his  results  by 
means  of  the  stomach-tube,  by  determining  the  progress  of  digestion 
and  the  exact  time  at  which  the  stomach  was  entirely  empty  after 


DIET  IN  DISEASED  OF  THE  UTOMACH 


417 


eating  a  certain  quantity  of  a  special  food.     The  table  ^  shows  the 
period  of  time  it  takes  a  given  quantity  of  food  to  leave  the  stomach : 


One  to 
100-200  gm. 

220  -m. 

200  gm. 

200  jrm. 

200  gm. 

200  gm. 

203  gm. 
100-200  gm. 

200  gm. 

100  gm. 

Two  to 

200  gm. 

200  gm. 

200  gm. 

200  g-m. 
300-500  gm. 
300-500  gm. 
300-500  gm. 

100  gm. 

100  gm. 

250  gm. 

250  gm. 
72  gm. 
200  gm. 
200  gm. 
200  gm. 
200  gm. 
150  gm. 
150  gm. 
150  gm. 
150  gm. 

150  gm. 

150  gm. 

150  um. 

70  gm. 

70  gm. 

70  gm. 

50  gm. 


two  hours: 
pure  water, 
earbonated  water, 
tea,  alone, 
cotfee,  alone, 
cocoa,  alone, 
beer. 

light  wines, 
boiled  milk, 
meat  broth,  alone. 
eggs,  soft. 

three  hoxirs: 

coffee  with  cream. 

cocoa  with  milk. 

Malaga  wine. 

"Ofner"  wine. 

water. 

beer 

boiled  milk. 

eggs,    raw    and    scrambled, 

hard-boiled  or  as  omelet. 

beef-sausage,  raw. 

calves'  brains,  boiled. 

calves'  thymus,  boiled. 

oysters,  raw. 

carp,  boiled. 

pike,  boiled. 

shellfish,  boiled. 

cod,  boiled. 

cauliflower,,  boiled. 

cauliflower,  as  salad. 

asparagus,  boiled. 

potatoes,     boiled     in     salt 

water. 

mashed  potatoes. 

stewed  cherries. 

raw  cherries. 

white  bread,   old   or   fresh, 

dry  or  with  tea. 

pretzels. 

zwieback,    fresh    or    stale, 

dry  or  with  tea. 

Albert  biscuits. 


Three  to  four  hours: 

230  gm.  young  chicken,  boiled. 

230  gm.  partridge,  boiled. 
220-260  gm.  pigeon,  boiled. 

195  gm.  pigeon,  fried. 

250  gm.  beef,  raw,  boiled,  lean. 

250  gm.  calves'  feet,  boiled. 

160  gm.  ham,  boiled. 

160  gm.  ham,  raw. 

100  gm.  veal,  warm  and  cold,  lean. 

100  gm.  beefsteak,   broiled,   cold    or 
warm. 

100  gm.  beefsteak,  raw,  scraped. 

100  gm.  tenderloin. 

200  gm.  Rhine  salmon,  boiled. 
75  gm.  caviare,  salted. 

200  gm.  sardines    in    vinegar,    kip- 
pered herring. 

150  gm.  blackbread. 

150  gm.  barley  bread. 

150  gm.  wheat  bread. 
100-150  gm.  Albert  biscuits. 

150  gTQ.  potato,  as  vegetable. 

150  gm.  rice,  boiled. 

150  gm.  kohlrabi,  boiled. 

150  gm.  carrots,  boiled. 

150  gm.  spinach,  boiled. 

150  gm.  cucumber  salad. 

150  gm.  radishes,  raw. 

150  gm.  apples. 

Four  to  five  hours: 

210  gm.  pigeon,  broiled. 

250  gm.  fillet  of  beef,  broiled. 

250  gm.  beefsteak,  broiled. 

250  gm.  beef  tongue,  smoked. 

100  gm.  smoked  beef  in  slices. 

250  gm.  hare,  broiled. 

240  gm.  partridge,  broiled. 

250  gm.  goose,  broiled. 

280  gm.  duck,  broiled. 

200  gm.  herring,  salted. 

150  gm.  lentils,  mashed. 

200  gm.  peas  as  puree. 

150  gm.  string- beans. 


Penzoldt  has  also  constructed  a  series  of  four  diet-lists  based  on  the 
length  of  time  at  which  various  foods  leave  the  stomach,  depending 
upon  their  mode  of  preparation  and  on  other  (jualities  of  the  food. 
They  agree  in  the  main  with  Leube's  diet-lists,  but  are  more  complete 
and  exact. 

These  tables  of  Penzoldt  are  valuable  as  a  basis  for  the  selection  of 
food  in  gastric  disturbances.  In  these  cases  it  is  important  that  the 
food  be  quickly  dissolved  in  the  gastric  secretion,  that  it  be  readily 
absorbed,  that  it  be  neither  fermented  nor  decomposed  while  being 


27 


iDeutsch.  Arch.  f.  klin.  Med.,  1893,  p.  578,  No.  57. 


418 


DIET  IN  DISEASE 


PENZOLDT'S   DIET-LISTS. 

Diet  I.  {about  Ten  Days). 


Largest 
Food  or  drink.    rSl't 
one  time. 


Meat  broth  .  . 
Cows'  milk  .  . 

Eggs    .... 


Meat  solution   . 
(Leube-Rosen- 
.    thai). 

Cakes.  (Albert 

biscuits)    .  .   . 
Water 


250  gm. 
250  gm. 

lor  2 
30-40  gm. 


6 
Ys  liter. 


Method  of 
preparation. 


From  beef. 


Special    require- 
ments. 


Well 


Without    fat,    or  Slowly, 
not  salted, 
boiled    orlEntire    milk  (or  If  desired,  with  a 


How  to  be  eaten. 


sterilized.  lime-water  Ia 

milk  %). 
Very    soft,    just  Fresh, 
heated  or  raw. 


Should  have 
only  a  slight 
meat  broth 
odor. 


little  tea. 

If  taken  raw,  should 
be  stirred  into  the 
warm,  not  boiling, 
meat  broth. 

In  teaspoonful  doses, 
stirred  in  meat 
broth. 


Without  sugar. 

Ordinary  water  Not  too  cold. 
or  natural  car- 
bonated water 
with  a  small 
percentage  of 
COo  (seltzer). 


Diet  II.  {about 

Ten  Days). 

Calves'  brain  .   . 

100  gm. 

Boiled. 

Freed  from  all 
membranes. 

Best  taken  in  meat 
broth. 

Thymus  (calf)  . 

100  gm. 

Boiled. 

Freed  from  all 
membranes. 

Best  taken  in  meat 
broth. 

Pigeon 

1 

Boiled. 

Only    if    young, 
without     skin, 
tendons   and 
the  like. 

Best  taken  in  meat 
broth. 

Chicken    .... 

As  large  as 

Boiled. 

As  above  (no  fat- 

Best taken  in  meat 

a  pigeon. 

tened  chicken). 

broth. 

Raw  beef .... 

100  gm. 

Chopped  fine  or 

From  the  tender- 

To be  eaten  with 

scraped,  with  a 

loin. 

cakes. 

little  salt. 

Rawbeef-sausage 

100  gm. 

Without  any  ad- 
ditions. 

Smoked  a  little. 

To  be  eaten  with 
cakes. 

Tapioca    .... 

30  gm. 

Boiled  with  milk 
to  make  gruel. 

Diet  III.  {about  Eight  Days). 

Pigeon 

1 

Broiled  with 
fresh  butter. 

Only  young  bird, 
skin,  etc. 

Without  gravy. 

Chicken    .... 

1 

Broiled  with 
fresh  butter. 

Only  young  bird, 
skin,  etc. 

Without  gravy. 

Beefsteak    .  .  . 

100  gm. 

With  fresh butteriFrom  the  tender- 
half-rare  (Eng-     loin,  well 
lish).                      beaten. 

Without  gravy 

Ham 

100  gm. 

Raw,  scraped       Smoked  a  little, 
fine.                        without  the 

With  white  bread. 

bone. 

Milk  bread.Zwie- 

50  gm. 

Crisped,  baked. 

Stale  (so-called 

To  be  carefully  mas- 

back, or  Frie- 

rolls,  etc.). 

ticated  and  well 

berger  pretzels 

salivated. 

Potatoes    .... 

50  gm. 

(a)    Mashed,    (6) 
boiled    in  salt 

The  potatoes 

should  be 

water  and 

mealy  and 

mashed. 

crumble  on 
crushing. 

Cauliflower    .  . 

50  gm. 

As  a  vegetable 
boiled  in  salt 
water. 

Use  only  the 
flowers. 

digested  or  absorbed,  and  that  the  entire  process  be  attended  with  no 
discomfort.  It  must  be  borne  in  mind  that  the  digestibility  of  food 
varies  widely  with  the  individual  taste,  for  no  matter  how  digestible 


DIET  IX  DISEASES  OF  THE  STOMACH 


419 


Diet  IV. 

{about  Eight  to  Fourteen  Da 

5/«)- 

Largest 

Food  or  drink. 

quantity  to 

be  taken  at 

one  time. 

Method  of 
preparation. 

Special   require- 
ments. 

How  to  be  eaten. 

Venison    .... 

100  gm. 

Roasted. 

From  the  back, 
should  hang 
for  a  time. 

Partridge  .... 

1 

Roasted  without 
bacon. 

Young  birds, 
without,  skins, 
tendons,    legs, 
etc.,  should 
hang  for  a 
time. 

Roast  beef  .  .  . 

100  gm. 

Medium  to  rare. 

From   good, 
fatted  cattle ; 
beaten. 

Warm  or  cold. 

Fillet  of  beef .  . 

100  gm. 

Medium  to  rare. 

From  good, 
fatted  cattle ; 
beaten. 

Warm  or  cold. 

Veal 

Roasted. 
Boiled  in  salt 

Back  or  leg. 
All  fish  bones 

Warm  or  cold. 

Pike r 

Shad J 

Carp 1 

Trout L 

) 

100  gm. 

water   without 

should  be  care- 

>In the  fish  gravy. 

any   abditions. 

fully  removed. 

J 

Caviare     .... 

50  gm. 

Raw. 

Slightly  salt, 
Russian 
caviare. 

Rice 

50  gm. 

Mashed,  pushed 
through  a 
sieve. 

Asparagus   .   .   . 

50  gm. 

Boiled. 

Soft,  without  any 
of  the  hard 
parts. 

With  a  little  melted 
butter. 

Scrambled  eggs 

2 

With  a  little 

fresh  butter 

and  salt. 

Omelet  (souffle) 

2 

With  about  20 
gm.  of  sugar. 

Must  have  risen 
well. 

To  be  eaten  at  onoe. 

Fruit  sauce  .   .   . 

50  gm. 

From  fresh 
boiled  fruit  to 
be  strained 
through  a 
sieve. 

Free  from  all 
kernels  and 
peel. 

Red  wine  .... 

100  gm. 

Light,  pure  Bor- 
deaux. 

Or    some    corre- 
sponding kind 
of  red  wine. 

Slightly  warm. 

a  food  may  be,  if  it  is  unpalatable,  it  will  not  be  digested  properly. 
In  general  it  may  be  said:  First — that  in  acute  conditions  the  food 
should  be  of  such  a  character  that  the  stomach  should  be  spared  as 
much  work  as  possible ;  second — in  chronic  disturbances  it  is  im- 
portant to  supply  sufficient  quantities  of  nourishment  in  an  easily 
digestible  form,  so  as  to  maintain  the  body-weight  so  far  as  possible. 
In  determining  the  quantity  of  food  that  is  necessary  during  twenty- 
four  hours  the  amount  is  estimated  in  calories  of  heat.  As  is  well 
known,  a  human  being  at  rest  requires  35  calories  per  kilo  of  weight, 
whereas  while  he  is  performing  light  work  he  requires  40  calories. 
In  order,  therefore,  to  determine  the  exact  amount  of  nourishment  it 
is  only  necessary  to  know  the  weight  of  the  individual.  Inasmuch 
as  the  proteins  can  be  replaced  in  a  measure  by  the  carbohydrates  and 
fats,  an  interchange  of  any  of  these  three  food  elements  can  be  made 
according  to  the  patient's  condition.  The  following  tables,  taken 
from  Konig,^  give  the  composition  of  different  foods  and  the  number 
of  heat  units  they  produce.     When  the  weight  of  the  person  is  known, 

1  Die  menschlichen  Niihrunpfs-und  Genussmittel,  Berlin,   1883,  p.  53. 


420 


DIET  IN  DISEASE 


it  is  an  easy  matter  to  determine  whether  the  amount  of  nourishment 
given  is  sufficient  to  maintain  the  body-weight. 

It  is  well  too  to  weigh  every  patient  suffering  with  a  stomach  dis- 

CJOMPOSITION  OF  THE  MOST  COMMON  FOOD  SUBSTANCES. 
/.  Dairy  Products. 


Protein. 

Fat. 

Carbohydrates. 

Calories. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  100. 

Cows'  milk    .... 

4.00-4.30 

3.00-3.80 

3.70 

64.00 

Cream 

3.61 

26.75 

3.52 

276.01 

Butter 

0.50 

90.00 

0.50 

837.00 

Whey 

0.50 

0.30 

3.60 

Buttermilk    .... 

3.00 

1.30 

3.00 

0.70 

lactic  acid 

3.67 

Kumiss    (of   cows'  ) 
milk) / 

3.35 

2.07    - 

1.90 
:        alcohol 
0.80 
carbonic  acid 

-     32.99 

I 

Cheese  (cream)     .    . 

25.00 

30.00 

3.00 

394.00 

Cheese 

33.00 

9.00 

5.00 

240.00 

Esrsr 

12.50 

12.00 

!           0.50 

165.00 

II.  Meat  and  Game. 


Beef  (fat) 

Beef  (lean)    .    .    .    . 

Veal  ffat) 

Veal  (lean)  .  .  .  . 
Mutton  (veiy  fat)  . 
Mutton  (leaner)  .  . 
Pork  (fat)  .  .  .  . 
Pork  (lean)  .  .  .  . 
Ham  (Westphalian) 
Sweet  bread  .... 
Pulverized  meat   .    . 

Poultry 

Spring  chicken  .  . 
Duck  (wild)      .    .    . 

Squab     

Game 

Hare 

Venison 

Pike 

Carp 

Shellfish 

Salmon 

Sardellen 

Oystere  ...... 

Salt  herring  .... 

Caviare 


17.19 
20.78 
18.88 
19.84 
14.80 
17.11 
14.54 
20.25 
23.97 
22.00 
64.50 
22.00 
18.49 
22.65 
22.14 
23.00 
23.34 
19.77 


18.50 
20.61 
17.09 
15.01 
22.30 
4.95 
19.50 
28.04 


26.38 
1.50 
7.41 
0.82 

36.39 
5.77 

37.34 
6.81 

36.48 
0.40 
5.24 
1.00 
9.34 
3.11 
1.00 
1.00 
1.13 
1.92 


///.  Fish. 


Wheat  flour  .  . 
Rye  flour  .  .  . 
Wheaten  bread 


IV.  Cereals 

0.50 

8.50 

10.00 

6.00 


0.50 
1.09 
9.34 
6.42 
2.21 
0.37 
17.00 
16.26 


and  Vegetables. 

Tiuce 
1.25 
2.00 
0.75 


0.07 
0.05 

1.50 

2.28 

1.20 
2.33 
0.76 

0.19 
1.42 

0.75 


2.85 
0.45 

0.50 

7.82 


86.50 
73.00 
69.00 
52.00 


315.81 

99.15 

146.61 

86.97 
399.31 
120.81 
406.88 
146.36 
453.69 

93.92 
322.53 
100.00 
167.59 
131.36 
100.07 
103.60 
107.08 
105.44 


83.57 

94.64 

156.93 

132.93 

113.83 

24.00 


356.70 
345.78 
342.50 
245.00 


Dityr  IS  1)1  si: ASKS  of  the  stomach 


421 


Cereals  and  Vegetables  (Continued). 


Rve  bread . 
R)ll    •    • 
Zwieback   . 
Cauliflower 
Carrots  .    . 
Asparagus . 
Rice    .    .    . 
Beans .    .    . 
Peas    .    .    . 
Potatoes 
Oatmeal 
Barley  meal 
Spinach  .    . 
Pickles  .    . 


Protein. 


Percent. 

4.50 

6.82 

9.50 
2.00-5.00 

1.04 

2.00 

5.50 
19.50 
19.50 

1.50 
12.60 

8.31 

3.49 

1.02 


Fat. 


Per  cent. 
1.00 
0.77 
1.00 
0.40 
0.21 
0.30 
1.50 
2.00 
2.00 

5.26 
0.81 
0.58 
0.09 


Carbohydrates. 


Per  cent. 
46.00 
43.72 
75.00 

4.00 

6.74 

2.50 
76.00 
52.00 
54.00 
20.00 
66.77 
75.19 

4.44 

0.95 


Calories. 


Per  100. 

216.00 

213.87 

356.00 

35.00 

33.85 

21.00 

348.10 

311.75 

319.95 

88.00 

338.80 

323.00 

38.00 


V.  Soups  and  Beverages. 


Milk  soup,  with 
wheat  flour  .    . 

Meat  broth  (ordi- 
nary)  

Meat-juice  (pressed) 

Beef-tea 

r 

Leube's  meat  solu- 
tion      

I 
Malt  extract .... 
Barley  soup  .... 
Rice  pap,  with  milk 

Coflfee 

Tea 

Beer 

Porter 


5.00 


3.25 


0.40 

0.60 

6.00-7.00 

0.50 

0.50 

0.50 

9.00-11.00 

protein 

1.79-6.50 

peptone 

8.00-10.00 

55.00 

1.50 

1.00 

11.00 

8.80 

3.50 

28.60 

3.12 

5.18 

12.38 

0.50 

5.25 

0.30 

0.70 

6.00 

0.30 

15.00 


112.00 


258.30 

60.96 

182.61 


6.00 


VI.  Fruits. 


Apples  .  . 
Pears  .  .  . 
Plums  .  . 
Peaches .  . 
Grapes  .  . 
Strawberries 
Chestnuts  . 
Sugar-cane 
Honey    .    . 


Free  acid. 


Per  cent. 
0.82 
0.20 
1.50 
0.92 
0.79 
0.93 


Protein. 


Per  cent. 
0.36 
0.36 
0.40 
0.65 
0.59 
0.54 
5.48 

1.20 


Fat. 


Per  cent. 


0.45 
1.37 


Carbo- 
hydrates. 


Per  cent. 
7.22 
3.54 
4.68 
7.17 
1.96 
1.01 
38.34 
3.40 
5.28 


order  when  treatment  is  first  inaugurated,  and  to  repeat  this  from 
time  to  time  in  order  to  determine  whether  the  patient  is  gaining  or 
losing  flesh. 

The  diet  must  be  considered  from  the  standpoint  of  the  gastric 


422  DIET  IX  DISEASE 

secretion ;  there  may  exist,  on  the  one  hand,  the  condition  of  hyper- 
chlorhydria  and  hypersecretion;  on  the  other,  hypoehlorhydria  and 
anacidity. 

In  cases  of  hyperchlorhydria  an  abundant  protein  diet  is  indicated, 
inasmuch  as  the  excess  of  hydrochloric  acid  is  neutralized  by  this  class 
of  foods.  On  the  other  hand,  as  Riegel  points  out,  certain  cases  of 
hyperchlorhydria  at  times  do  better  upon  milk,  bread,  and  amylaceous 
foods  than  on  protein  foods.  Ordinarily  the  proteins  that  are  best 
adapted  for  patients  suffering  from  hyperchlorhydria  are  the  red 
meats  and  eggs,  whereas  the  carbohydrates  must  be  given  in  the  most 
easily  digestible  form. 

In  cases  of  hypoehlorhydria  there  is  a  diminution  of  the  gastric 
secretion ;  consequently  the  protein  foods  are  digested  with  difficulty, 
whereas  the  carbohydrates  are  more  easily  digested.  In  this  condi- 
tion, therefore,  only  very  tender  meats,  preferabh"  scraped,  are  to  be 
given,  whereas  such  easily  digestible  vegetables  as  spinach,  asparagus, 
mashed  potatoes,  and  farinaceous  foods  may  be  eaten  in  quite  large 
quantities.  In  hyperchlorhydria  and  hypoehlorhydria  a  reasonable 
amount  of  fat  must  be  eaten,  preferably  in  the  form  of  good  butter. 

The  diet  in  motor  disturbances  of  the  stomach,  as  in  atony  or  in 
dilatation,  depends  greatl}^  upon  whether  an  excess  or  a  deficiency  of 
gastric  juice  is  secreted :  if  there  is  an  increase,  an  excess  in  protein 
food  gives  the  best  results ;  if,  on  the  other  hand,  there  is  a  diminu- 
tion of  this  secretion,  protein  food  must  be  given  the  patient  in  the 
most  easily  digestible  form — e.  g.,  as  the  albumoses  and  peptones. 
The  carbohydrates  and  the  lighter  vegetables  may  be  given  in  some- 
what larger  proportion.  In  both  conditions  the  ingestion  of  fluids 
should  be  restricted  as  far  as  possible. 

Normally  the  appetite  is  a  fair  indication  of  the  number  of  calories 
of  heat  that  may  be  required;  in  conditions  of  gastric  disorder,  how- 
ever, this  is  not  the  case;  these  patients  lose  their  appetite,  and  con- 
sequently often  take  insufficient  nutrition.  In  those  instances  in 
which  the  gastric  disorder  is  somewhat  protracted  and  accompanied 
by  great  loss  of  weight,  and  in  which  the  patient  takes  insufficient 
nourishment,  it  need  only  be  borne  in  mind  that  such  a  patient,  rest- 
ing quietly  in  bed,  requires  fewer  calories  than  necessary  for  a  patient 
who  is  not  resting.  This  plan  may,  therefore,  be  used  with  advantage 
in  the  treatment  of  many  patients  suffering  from  stomach  disorders. 

Liquid  Foods  in  Gastric  Disorders.— In  those  cases  in  which  it  is 
necessary  to  spare  the  stomach  as  much  work  as  possible  milk  is  the 
food  that  is  usually  most  easily  borne.  In  order  to  supply  a  sufficient 
number  of  calories  it  must  be  taken  in  large  quantities,  frequently 
diluted  with  lime-water  or  barley-water  in  order  to  add  to  its  digesti- 
bility. In  those  cases  in  which  milk  is  not  well  borne  buttermilk, 
whey,  kumiss,  and  kefir  may  serve  as  substitutes.  Among  the  other 
forms  of  fluids  that  may  be  given  are  broths  (chicken,  beef,  mutton), 
bouillon,  beef-tea,  and  meat-juice.     Of  these,,  meat-juice  is  most  nu- 


DIET  IX  DISEASES  OF  THE  STOMACH 


423 


tritious.  Coffee  should  be  forbidden  in  patients  suffering  with  gas- 
tric disturbance  or  when  allowed  at  least  taken  very  weak.  Weak  tea 
may  be  taken  and  may  serve  as  a  vehicle  for  milk.  Cocoa  has  a  far 
higher  nutritive  value  than  coffee  or  tea  and  is  to  be  recommended. 
The  followijig  diet-lists,  devised  by  von  Noorden,^  indicate  how  an 
easily  digestible  diet,  containing  a  sufficient  number  of  calories  of 
heat  to  maintain  the  body-weight,  can  be  prepared: 


I.  A  Principally  Milk  Diet  with  Additions  of  Carbohydrates  in 
Liquid  Form. 


Milk,  1700  c.c 

Soup  of  tapioca  flour  30  gm.  and  10 
gm.  albumose  ^ 

Soup  of  40  gm.  wheat  flour,  with  some 
of  the  milk,  10  gm.  sugar,  and  1 

egg 

Total 


Protein. 


Per  cent. 
70.2 

10.0 


7.0 


87.2 


Fat. 


Per  ct. 
66.3 


5.5 


71.8 


Carbo- 
hydrates. 


Per  cent. 
69.7 

30.0 


40.0 


139.7 


Calories. 


1295 

164 

244 


1703 


//.    Principally  Milk  Diet  with  the  Addition  of  Carbohydrates  and  Fat 
in  Pap  Form  and  Soups. 


Protein. 

Fat. 

Carbo- 
hydrates. 

Calories. 

Milk,  1500  c.a   .   . 

Soup  of  15  gm.  sago,  10  gm.  butter, 

1  egg,  10  gm.  albumose  ..._.. 
Pap  of  80  gm.  corn  flour,    1  egg,  10 

gm.  sugar  (two  meals) 

Per  cent. 
62 

17 

7 

Per  ct. 

58.5 

13.5 
5.5 

Per  cent. 
63 

15 

90 

1056 
257 

398 

Total 

86 

77.5 

168 

1711 

///.  Milk  Diet  with  Addition  of  Light  Pastry  and  Broths. 


MUk,  1250  c.c 

Meat  broth  with  1  egg;  10  gm.  of 
butter ;  50  gm.  of  fine  toasted  wheat 
bread 

Cakes,  70  gm. ;  butter,  15  gm.     .    .    ■ 

Soup  of  30  gm.  tapioca  flour,  1  egg, 
10  gm.  butter 

Total 


Protein. 


Percent. 
51 


10 
5 


73 


Fat. 


Perct. 
49 


14 
12 


89 


Carbo- 
hydrates. 


Percent. 

62 


30 
50 


30 


162 


Calories. 


878 


294 
337 

282 


1791 


1  Berliner  Klinik. 

2  10  gm.  albumose  are  contained  in  90  c.c.  of  Denayer's  peptone  preparation, 
In  22  gm.  of  Kemmerich's,  or  in  30  gm.  of  Koch's. 


424 


DIET  IN  DISEASE 


IV.  Milk  with  Tender  Meat,  Flour,  Butter,  and  Soups. 


Protein. 


Fat. 


Carbo- 
hydrates. 


Calories. 


Spring  chicken,  100  gm.    .    . 
Mashed  potatoes,  100  gm.  .    . 

Two  eggs 

Toasted  wheat  bread,  100  gm. 

Butter,  30  gm 

Trout,  100  gm 

Milk,  1250  C.C 

Total 


Per  cent. 
19.6 

2.0 
14.1 

7.0 


19.3 
51.0 


Per  cent. 

2.8 

4.0 
11.0 

0.5 
23.0 

2.1 
49.0 


113.0 


92.4 


Per  cent. 
20 
55 

52 


127 


106.4 
127.4 
160.1 
258.8 
213.9 
106.4 
878.0 


1851.0 


V.  Rich,  Not  Irritating  Diet. 


Protein. 


Fat. 


Carbo- 
hydrates. 


Calories. 


Tender  meat,^  250  gm. 

Cocoa,  20  gm 

Three  eggs 

100  gm.  zwieback  .  . 
100  gm.  wheat  bread   . 

50  gm.  cakes   .    .    .    . 

50  gm.  butter  .    .    .    . 

40  gm.  tapioca  flour  . 

40  gm.  corn  flour   .    . 

20  gm.  sugar  .  .  .  . 
1250  c.c.  milk  .    .    .    . 


Total 


Per  cent. 
49 

4 
21 

8 

7 

4 


51 


Per  cent. 
7.0 
6.0 
IG.O 
1.0 
0.5 
2.3 
44.0 


49.0 


144        125.8 


Per  cent. 


75 
55 
3G 


40 
40 
20 
52 


326 


266 
105 
235 
259 

187 
407 
164 
164 
82 
878 


2747 


Gelatinous  Forms  of  Food. — Gelatinous  articles  of  food,  as  gelatin, 
calves'  feet,  etc.,  are  easily  digested  and  readily  absorbed. 

Meats. — The  digestibility  of  meat  can  be  increased  by  chopping, 
beating,  grinding,  scraping,  etc. 

Eggs. — The  digestibility  of  eggs  depends  upon  their  mode  of  prep- 
aration; raw  and  soft-boiled  eggs  are  usually  the  most  easily  digesti- 
ble forms. 

Fish. — In  regard  to  fish,  those  containing  but  little  fat  are  to  be 
recommended  for  patients  suffering  from  gastric  disturbances,  such 
as  shellfish,  pike,  trout,  carp,  and  halibut. 

Carbohydrates. — The  number  of  vegetables  from  which  selection 
may  be  made  is  large.  The  secretions  from  the  mouth  and  intestines 
play  an  important  role  in  the  digestion  of  these  substances.     They 

1  Meat  of  various  kinds,  finely  chopped,  raw  or  fried  in  butter ;  cold  or  warm, 
taken  at  meals. 


DIET  ly;  DISEASES  OF  THE  STOMACH  425 

should  be  masticated  thoroughly.  In  those  eases  in  which  there  is 
danger  of  fermentation  they  should  be  given  with  caution.  The  best 
form  in  which  to  give  amylaceous  food  is  in  the  form  of  zwieback, 
toast,  stale  wheat  bread,  tapioca  flour,  oatmeal,  etc.  Ebstein  has 
highly  recommended  aleuronat  flour,  which  contains  about  80  per  cent. 
of  protein. 

Leguminous  foods  contain  a  considerable  amount  of  protein,  much 
of  which,  however,  is  not  absorbed.  They  are  apt  to  give  rise  to  con- 
siderable fermentation.  Potatoes  are  best  given  mashed  or  baked. 
Cabbage  contains  much  cellulose,  and  should  be  omitted  from  the 
diet  of  all  patients  suffering  from  stomach  disorders. 

Fruits  are  of  slight  nutritive  value,  but  give  a  relish  to  other  foods 
and  increase  intestinal  peristalsis. 

Fat  is  to  be  recommended  because  of  its  tendency  to  increase  the 
weight  of  the  patient,  and  also  because  of  its  high  calorie  value.  Some 
observers  claim,  however,  that  it  acts  as  an  irritant  to  the  stomach. 
It  is  true  that  many  patients  find  that  fat  meat,  greasy  gravies,  etc., 
give  rise  to  indigestion  and  often  to  nausea  and  vomiting.  Much 
depends,  however,  on  the  mode  of  preparation.  A  considerable 
amount  of  fat  may  be  given  in  the  form  of  fresh  butter  spread  on 
wheat  bread  or  toast.  Certain  forms  of  chocolate  contain  quite  a 
large  percentage  of  fat,  and  on  this  account  are  very  nutritious.  Of 
these,  Mehring's  Vigor  Chocolate  is  to  be  especially  recommended. 
Olive  oil  is  of  great  value  in  the  treatment  of  certain  gastric  dis- 
orders (see  p.  151). 

Concerning  the  relative  digestibility  and  nutritive  value  of  various 
liquid  and  solid  foods,  the  reader  is  referred  to  the  section  dealing 
with  this  subject. 

Special  Factors  bearing  on  the  Diet  in  Patients  Suffering  from 
Gastric  Disturbances. — 1.  Von  Noorden  ^  demonstrated  the  fact  that 
the  intestine  will  vicariously  perform  the  work  of  the  stomach  in 
conditions  in  which  the  secretory  function  of  the  latter  is  lost.  Thus, 
as  has  been  shown  by  Ewald,  Leube,  and  others,  in  cases  of  atrophy 
of  the  gastric  mucous  membrance  in  which  there  is  no  longer  any 
gastric  secretion  the  patient  may  maintain  his  weight,  for  the  in- 
testine assumes  the  digestive  function  normally  carried  on  by  the 
stomach.  Einhorn  ^  has  likewise  demonstrated  this  fact  in  cases  of 
achylia  gastrica.  The  point  to  be  borne  in  mind  is  that  even  in  cases 
in  which  the  secretory  action  of  the  stomach  is  lost  entirely,  the  intes- 
tine may  assume  this  function  of  the  stomach. 

2.  In  those  cases  in  which  it  is  necessary  to  spare  the  stomach,  as 
when  food  can  not  be  digested  or  is  vomited,  either  predigested  foods 
may  be  utilized  or  foods  may  be  administered  through  channels  other 
than  the  stomach.     Among  the  artificial  food  preparations  are  the 

1  Berliner  Klinik,  pt.  Iv. 

2  Medical  Record,  1892. 


426  DIET  ly  DISEASE 

albumoses  and  peptones,  Denayer's  Albumose-peptone,  Somatose,  Nu- 
trose,  and  Mosquera  Beef  Meal.  For  the  various  methods  of  feeding, 
the  reader  is  referred  to  the  sections  on  Rectal  Feeding,  Subcutaneous 
Feeding,  etc. 

3.  The  following  rules  for  eating  should  be  carried  out: 

(a)  Food  should  be  thoroughly  masticated ;  this  is  especially  im- 
portant in  those  cases  in  which  there  are  marked  gastric  disturbances. 
Biernacki  ^  and  the  authors  -  have  shown  the  importance  of  the  effect 
of  the  salivary  digestion  upon  the  gastric  secretion  in  so  far  that  an 
absence  of  salivary  secretion  not  only  results  in  an  absence  of  amyloly- 
sis,  but  that  the  proteolysis  is  much  retarded. 

( h )  The  meals  should  be  taken  at  regular  intervals  and  in  moderate 
quantities,  according  to  the  nature  of  the  gastric  disease ;  this  rule 
must  be  varied  under  certain  conditions ;  e.  g.,  small  frequent  meals 
should  be  taken  in  atony,  whereas  under  other  conditions,  such  as 
hyperchlorhydria,  somewhat  larger  meals  should  be  given  but  three 
times  daily. 

(c)  The  temperature  of  the  food  is  also  an  important  factor  in  the 
treatment  of  gastric  disturbances;  as  Uft'elmann  has  pointed  out,  the 
food  should  be  taken  at  a  temperature  between  98°  and  100°  F.  The 
ingestion  of  very  hot  food  is  believed  to  be  a  frequent  cause  of  ulcer 
of  the  stomach.  On  the  other  hand,  Wegele  attributes  the  dyspepsia 
of  many  Americans  to  the  taking  of  ice-cold  water  and  other  drinks, 

{d)  The  question  of  rest  or  exercise  after  eating  is  one  that  is  of 
considerable  importance  to  those  suffering  from  gastric  disturbances. 
It  is  generally  admitted  that  violent  exercise  should  not  be  indulged 
in  after  eating.  According  to  Schule,^  patients  suffering  from  super- 
acidity  should  not  sleep  after  eating.  From  experiments  the  authors 
have  determined : 

(1)  Under  normal  conditions  the  secretory  as  well  as  the  motor 
functions  of  the  stomach  are  not  interfered  with  during  rest;  during 
sleep  after  a  meal,  however,  the  secretory  function  remains  normal, 
but  the  motor  function  is  slightly  disturbed. 

(2)  In  cases  of  hyperchlorhydria  with  normal  motor  function  the 
acidity  is  reduced  and  the  motor  function  remains  normal  while  rest- 
ing, whereas  during  sleep  the  acidity  remains  about  the  same  and  the 
motor  function  is  impaired. 

(3)  In  conditions  of  hyperchlorhydria  with  motor  insufficiency  the 
acidity  is  lessened  and  the  motor  function  impaired  during  rest, 
whereas  during  sleep  the  acidity  is  still  further  decreased  and  the 
motor  function  still  further  impaired. 

(4)  In  conditions  of  hypochlorhydria  with  normal  motor  activity 
the  acidity  seems  to  be  increased  and  the  motor  function  remains 

1  Zeitschr.  f.  klin.  Med.,  vol.  xxi. 

2  International  Medical  Magazine.  August,  1896. 

3  Berlin,  klin.  Wochenschr.,  1895,  No.  50. 


DIET  IN  DISEASES  OF  THE  STOMACH  427 

normal  during  rest,  whereas  during  sleep  the  acidity  is  increased  and 
the  motor  function  is  disturbed. 

(5)  In  conditions  of  hypochlorhydria  with  diminished  motor  ac- 
tivity the  acidity  seems  to  be  increased  and  the  motor  function  im- 
proved during  rest,  whereas  during  sleep  the  acidity  remains  about 
the  same  and  the  motor  fuuction  is  interfered  with. 

From  these  observations  it  appears  that  in  conditions  of  gastric 
disturbances  accompanied  by  hyperchlorhydria  and  hypochlorhydria 
and  in  motor  disturbances  of  the  stomach  the  gastric  digestion  is 
improved  during  rest,  but  impaired  by  sleep,  after  meals. 

(6)  Tobacco. — Inasmuch  as  tobacco  is  frequently  the  cause  of  cer- 
tain gastric  disturbances  such  as  chronic  gastritis  its  use  should  be 
interdicted  if  possible  in  patients  affected  with  digestive  disorders. 
It  often  produces  hyperacidity  and  in  habitual  smokers  in  whom  it 
is  impossible  to  entirely  abandon  smoking,  the  number  of  cigars  con- 
sumed should  be  materially  reduced. 

SPECIAL  CURES  IN  THE  TREATMENT  OF  THE  DISEASES  OF  THE 

STOMACH 

Among  the  special  forms  of  treatment  recommended  in  gastric  dis- 
turbances may  be  mentioned  the  rest  cure,  the  milk  cure,  the  grape 
cure,  and  forced  feeding  or  gavage. 

The  rest  cure,  first  devised  by  Weir  Mitchell  and  subsequently 
especially  developed  by  Burkhart,  in  Germany,  for  the  treatment  of 
gastric  conditions,  plays  an  important  role  in  the  treatment  of  stomach 
disorders.  This  treatment  is  especially  useful  in  cases  of  neurasthenia 
with  severe  anorexia  and  emaciation.  It  is  also  useful  in  the  treat- 
ment of  ulcer,  gastritis,  atony,  and  gastroptosis. 

The  rest  treatment  in  gastric  disorders  should  be  carried  out  for 
from  six  to  eight  weeks.  The  results  that  follow  this  plan  of  treat- 
ment are  often  marvellous.  The  patient  should  be  confined  to  bed  a 
large  part  of  this  time  and  given  a  varied  diet,  food  being  supplied 
every  two  to  three  hours.  Boas  advises  that  instead  of  the  large 
quantities  of  milk  usually  prescribed,  the  patient  will  do  better  if 
given  1/^  to  1  liter  of  cream  daily  in  portions  of  150  to  200  c.c.  In 
addition  to  the  protein  food  he  advises  a  diet  rich  in  carbohydrates 
and  fats.  In  case  of  constipation,  milk-sugar,  honey,  marmalade, 
buttermilk,  sour  milk,  kefir,  or  yoghurt  may  be  added  to  the  dietary 
to  advantage. 

Boas'  diet  list  is  as  follows: 

7  A.  M. :  I  liter  vigor  chocolate  in  cream. 

3  to  4  zwieback  (2  rolls),  20  to  30  gm.  butter. 
10.30  A.M.:     Cold  or  warm  meat,  eggs,  egg  foods,  wheat  bread  (perhaps  Graham 
bread),  20  gm.  butter. 
150  gm.  cream. 
Preserves  or  stewed  fruit. 
11  A.M. :  i  liter  of  soup. 


428  DIET  IN  DISEASE 

Potatoes  or  other  vegetables  in  puree  form. 

Meat  and  fish. 

Salad. 

Stewed  fruit  (sweet)   or  raw  fruit. 

Cider,  grape  juice,  or  lemon  albumin. 
4.30  P.M.:     CofTee  or  tea  with  cream    (150  gm.),  zwieback,  crackers,  Graham 

bread,  butter   (20  gm.),  or  honey. 
8  P.  jr. :  Eggs  or  egg  foods. 

Wheat  bread,  Graham  bread,  butter   ( 30  gm. ) . 

Stewed  fruit. 

Two  glasses  of  fruit  wine  or  one  bottle  of  malt  beer. 
9.30  P.  M. :     200  gm.  cream  with  two  to  three  crackers  or  zwieback  with  butter. 

For  a  further  consideration  of  the  method  and  plan  of  conducting 
the  rest  treatment  systematically  the  reader  is  referred  to  the  section 
dealing  with  this  subject. 

The  Milk  Cure. — The  underlying  principle  of  the  milk  cure  con- 
sists in  the  ingestion  of  large  quantities  of  milk,  either  alone  or  to- 
gether with  other  foods.  Under  normal  conditions,  when  taken  alone 
in  large  quantities — say  three  liters  a  day — milk  does  not  suffice  as 
a  food;  in  certain  digestive  disturbances,  however,  milk  given  alone 
for  a  time  forms  a  useful  food  and  allows  the  stomach  to  regain  its 
normal  tone  and  functions.  ]\Iilk  is  especially  useful  in  the  treatment 
of  ulcer  of  the  stomach  and  in  certain  forms  of  chronic  gastritis;  it  is 
particularly  useful  in  the  secondary  forms  of  gastritis,  as  those  de- 
pending upon  tuberculosis,  anemia,  etc.  In  some  cases  of  nervous 
dyspepsia  milk  cures  sometimes  effect  remarkable  results,  whereas  in 
others  milk  disagrees  and,  as  a  consequence,  the  milk  cure  can  not  be 
undertaken.  "When  there  is  a  diminution  or  an  absence  of  acid  in  the 
stomach,  milk  is  usually  not  well  borne.  It  is  also  contraindicated  in 
severe  cases  of  atony  and  of  dilatation,  in  intestinal  conditions  accom- 
panied by  extreme  flatulence  and  chronic  diarrheas. 

When  milk  is  given  in  large  quantities  in  addition  to  other  foods, 
it  is  more  frequently  better  borne  and  is  less  apt  to  disagree.  One 
of  the  disadvantages  of  the  milk  cure  is  the  obstinate  constipation  the 
milk  is  apt  to  induce.  Milk  can  often  be  rendered  more  digestible 
by  the  addition  of  barley-water,  lime-water,  milk  of  magnesia,  and  the 
like,  or  small  quantities  of  coffee,  tea,  or  whisky  may  be  added  to  it. 
When  milk  disagrees,  cream,  buttermilk,  kefir,  kumiss,  or  matzoon 
may  be  given  as  a  substitute  for  it.     (See  Milk  Cure.) 

Forced  Feeding  or  Gavage. — This  method  was  first  introduced  by 
Debove,  and  consists  in  introducing  milk,  eggs,  and  meat-extracts  into 
the  stomach  by  means  of  the  stomach-tube.  It  is  especially  useful  in 
nervous  anorexia,  in  which  cases  there  is  great  danger  of  starvation 
from  lack  of  nourishment. 

The  Grape  Cure, — In  this  form  of  treatment  the  patient  lives  ex- 
clusively upon  grapes;  it  is  especiallj^  useful  in  plethoric  individuals, 
in  whom  it  is  important  to  diminish  the  weight;  in  chlorotic  girls 
suffering  with  dyspepsia,  and  in  certain  cases  of  nervous  dyspepsia. 


DIET  IS  DISEASES  OF  THE  STOMACH  '        429 

The  Fast  Cure. — Spivak  (Colorado  Medicine,  Dec.  1916)  has  ad- 
vocated prolonged  fasting  as  a  therapeutic  measure  in  diseases  of  the 
gastro-intestinal  tract,  thus  representing  the  employment  of  rest  in 
the  treatment  of  diseases  of  other  portions  of  the  body.  The  total 
fasting  may  be  continued  without  harm  for  many  days,  usually  with 
much  benefit.  Except  in  the  more  severe  cases,  the  rest  in  bed  may 
be  dispensed  with  and  the  patient  be  allowed  to  be  up.  This  method 
is  according  to  this  author  of  especial  value  in  the  treatment  of  gas- 
tritis, hyperacidity,  anacidity,  ulcer  of  the  stomach  and  of  the  small 
or  large  bowel.  "The  process  of  fasting  is  not  combined  with  pain 
or  distress.  At  the  end  of  the  second  day  or  the  beginning  of  the 
third  day,  the  desire  for  food  may  be  entirely  absent.  Eventually  a 
normal  and  healthy  appetite  comes  and  then  the  stomach  and  in- 
testines are  found  in  a  condition  to  do  their  work  efficiently.'' 

DIET  IN  DYSPHAGIA 

Dysphagia  may  be  due  to  any  obstruction  in  the  mouth,  pharynx, 
or  esophagus.  The  difficulty  and  pain  induced  by  swallowing  must 
be  obviated  by  lessening  the  efforts  at  deglutition  as  much  as  possible ; 
for  this  reason  food  must  be  given  in  a  concentrated  form,  and  only 
in  a  liquid  or  semisolid  state ;  milk,  egg-albumin,  and  the  concentrated 
liquid  beef  preparations  are  especially  useful  in  this  condition.  In 
those  cases  in  which  food  can  not  be  swallowed  in  sufficient  quantities 
the  patient  must  be  fed  through  the  stomach-tube.  In  this  way 
broths,  gruel,  milk,  and  the  like  can  be  passed  into  the  stomach.  In 
very  aggravated  cases  gastrotomy  must  be  performed  to  prevent 
starvation. 

DIET  IN  ACUTE  GASTRITIS 

Oser  has  said  that  "every  case  of  acute  catarrh  of  the  stomach  has 
a  natural  tendency  to  heal  of  its  own  accord  unless  a  chronic  form 
is  produced  by  a  mistaken  diet  or  wrong  medication."  It  is  a  gen- 
erally admitted  fact  that  in  the  treatment  of  this  condition  the  diet 
plays  the  leading  role.  The  first  step  in  the  treatment  consists  in 
securing  absolute  rest  for  the  stomach  and  a  total  abstinence  from 
food  for  at  least  twenty-four  hours.  This  procedure  is  sometimes 
very  difficult  to  carry  out,  for  many  patients  believe  that  food  is  nec- 
essary for  them,  and  that  they  can  secure  relief  more  quickly  by 
taking  nourishment.  The  nausea  and  vomiting  which  are  present  in 
more  or  less  degree  in  this  condition,  and  which  are  aggravated  by  the 
taking  of  food,  will  soon  convince  the  patient  of  the  necessity  of  ab- 
staining from  food.  The  thirst  is,  however,  so  severe  in  these  cases 
that  patients  may  be  allowed  to  rinse  the  mouth  with  water  fre- 
quently, to  retain  tiny  bits  of  ice  in  the  mouth,  or  even  to  drink  very 
small  quantities  of  carbonated  waters.  With  this  plan  of  treatment 
recovery   generally   follows  in  two   or  three   days.     After   the   first 


430  DIET  IN  DISEASE 

twenty-four  hours  feeding  may  be  begun  by  giving  cautiously  small 
quantities  of  milk  diluted  with  lime-water,  broths,  and  egg-albumin; 
these  can  gradually  be  increased  in  quantity,  and  during  the  next  day 
or  two  boiled  chicken,  sweetbreads,  scraped  beef,  in  addition  to  toast, 
may  be  added. 

The  authors  are  accustomed  to  prescribe  the  following  diet  about 
the  second  or  third  day  after  an  attack  of  acute  gastritis :  ^ 

Calories. 

7  A.  M. :      150  gm.  milk  with  lime-water    101 

9  A.  M.:      100  gm.  egg-albumin  flavored  with  orange-  or  lemon-juice 53 

11a.  m.  :      150  gm  broth  with  egg   84 

1  P.  M. :      150  gm.  milk  with  lime-water    101 

3  P.  M. :         5  gm.  Armour's  soluble  beef  in  water    10 

5  p.  M. :      100  gm.  egg-albumin  flavored  with  orange-  or  lemon-juice 53 

7  P.  M. :      150  gm.    milk  with  lime-water    101 

503 

After  the  third  day  the  diet  is  increased  as  follows : 

Calories. 

7  A.  M. :      150  gm.  milk   ( 101 )   with  70  gm.  toast    ( 182 )    283 

9  A.  M. :         2  very  soft-boiled  eggs 160 

11  A.M.:     200  gm.  bouillon  with  1  egg  85 

1  P.  M. :      100  gm.  rice  cooked  in  milk    177 

70  gm.  toast 1 82 

3  P.  M. :      100  gm.  egg-albumin   (.53)   with  50  gm.  crackers   ( 187)    240 

5  P.  M. :      150  gm  milk  with  70  gm.  toast 283 

7  P.M.:      100  gm.  egg-albumin  flavored  with  orange-  or  lemon-juice 53 

1463 

The  following  table,  taken  from  Boas'  Magenkrankheiten,  gives  a 
diet-list  to  be  followed  after  the  second  or  third  day  following  an 
attack  of  acute  gastritis: 

Diet  for  Acute  Gastritis. 

Calories. 

8  A.  M.:     200  gm  milk  with  tea    135.0 

50  gm  zwieback       178.9 

10  A.  M. :     200  g-m.  bouillon  with  egg 86.0 

12     M. :       200  gm.  milk  soup    227.2 

50  gm.  toasted  bread 129.4 

3  P.  M. :      130  gm.  milk    101.2 

50  gm.  cakes 187.0 

7  p.  M. :     200  gm  milk  soup  with  rice   235.4 

50  gm.  zwieback 178.9 


1459.0 
DIET  IN  CHRONIC  GASTRITIS 

The  dietetic  treatment  of  chronic  gastritis  is  of  far  greater  im- 
portance than  the  treatment  of  this  disease  by  the  use  of  drugs.  The 
diet  must  be  varied  according  to  th€  stage  of  the  disease.  Inasmuch 
as  the  motor  function  of  the  stomach  is  usually  unimpaired  and  only 

1  In  comparing  these  diet-lists  slight  discrepancies  in  the  calorie  values  of  the 
foods  will  be  noted.  These  differences  have  arisen  from  some  authors  using  the 
calorie  values  of  raw  foods,  while  others  have  computed  the  values  of  cooked 
foods.  In  the  diet-lists  given  by  the  authors  calorie  values  of  foods  as  prepared 
for  the  table  are  given. 


DIET  IN  DISEASES)  OF  THE  STOMACH  431 

the  secretory  function  affected,  the  most  easily  borne  forms  of  food 
are  liquids,  such  as  broths;  unfortunately,  these  foods  do  not  furnish 
sufficient  nutriment  to  sustain  the  patient.  Their  nutritive  value  may 
be  incrcasetl  by  the  addition  of  beef-extracts,  eggs,  barley  and  rice, 
peptones,  somatose,  etc.  The  diet  should  vary  according  to  the  char- 
acter of  the  gastritis;  in  those  cases  in  which  the  gastric  secretion 
has  entirely  or  almost  entirely  disappeared,  protein  food  is  digested 
with  great  dittieulty ;  it  must,  therefore,  be  given  in  the  most  digesti- 
ble form;  of  these  foods,  scraped  beef,  stewed  beef,  stewed  chicken, 
broiled  steak,  and  boiled  sweetbreads  are  especially  to  be  recommended. 
Vegetables  should  also  be  given  in  the  most  digestible  form,  best  as 
a  mush.  Milk  is  useful  in  most  cases;  occasionally,  however,  it  is  not 
well  borne;  when  this  is  the  case,  it  can  be  made  more  agreeable  by 
adding  small  quantities  of  rice,  potatoes,  or  cocoa  to  it,  or  kefir, 
kumiss,  or  matzoon  may  be  substituted  for  it.  In  those  conditions  in 
which  considerable  acid  still  remains  in  the  stomach  meats  in  various 
forms  are  very  acceptable;  to  this  list  may  be  added  fish  and  eggs; 
vegetables,  such  as  mashed  potatoes,  spinach,  mashed  carrots,  es- 
pecially in  the  form  of  purees,  are  to  be  recommended.  In  all  in- 
stances fat  should  be  given  in  any  easily  digestible  form — as  good 
butter,  cocoanut-butter,  or  ]\[ehring's  Vigor  Chocolate.  It  is  im- 
possible to  formulate  exact  rules  as  to  the  number  of  meals  that  should 
be  eaten  and  the  quantity  that  should  be  taken  at  each  meal ;  in  a 
general  way,  small  frequent  meals  are  best  borne.  Mineral  waters 
are  often  useful  in  the  treatment  of  chronic  gastritis,  and  the  saline 
waters  and  alkaline  saline  waters  are  especially  to  be  recommended;  of 
these,  the  waters  of  Kissingen,  Homburg,  Saratoga  (Congress).  Carls- 
bad, Marienbad,  and  Saratoga  (Hathorn)  are  especially  noted  for 
their  usefulness  in  the  treatment  of  chronic  gastritis.  Water  should 
be  taken  in  small  quantities  between  meals.  Alcoholic  stimulants  or 
any  strong  stimulants  should,  as  a  rule,  be  omitted ;  when  utilized, 
they  should  be  given  in  small  quantities  and  best  diluted  with  mineral 
waters.  Salt  and  spices  may  be  allowed  occasionally  in  small  quan- 
tities. 

Ewald  recommends  the  following  diet  in  chronic  gastritis: 

8  A.M.:  1.50-200    gm.    tea    with    75-100    gm.    of    stale    bread,    toast    or 

zwieback. 
10  A.M.:  50  gm.  bread,   10  gm.  butter,  50  gm.  cold  meat,  or  occasionally 

one  glass  of  light  wine  or  one-third  of  a  liter  of  milk. 
2  P.M.:  150-200  gm.  water,  milk,  or  bouillon  from  white  meats;   100-125 

gm.  meat  or  tish ;  80-100  gm.  vegetables:  80  gm.  compote. 
4  or  5  p  M. :     One-fourth   to   one-third  of  a   liter   of   warm  milk    (occasionally 

mixed  with  cocoa  or  coffee ) . 
7  to  8  P.M.:     200  gm.  .soup  or  pap;  50  gm.  white  bread:    10  gm.  butter. 
Occasionally  at    10   o'clock   p.m.:     50  gm.   wheat   bread    (biscuit  or   zwieback); 

one  cup  of  tea. 

The  authors  have  found  the  following  diet-list  useful  in  cases  of 
chronic  gastritis: 


432  DIET  IN  DISEASE 

Calories. 

s  A.  M. :     200  gm.  milk  flavored  with  tea   135 

60  gm.  stale  bread  ( 154)  with  40  gm.  butter  (326)    480 

1  soft-boiled  egg    80 

10  A.M.:      100  gm.    scraped    beef    (119)    with   60   gm.    stale   bread   or    toast 

(154)      273 

(or  chicken  sandwich   (260)   or  50  gm.  sherry   (60)   with  egg   (80)) 

11  A.  M. :      Bouillon  with   egg 84 

100  Jim.  cliicken    106 

( or  100  gm.  lamb  chops  ( 230 )  ) 
or  lOU  gm.  broiled  steak   (209) 

10(1  gm.  spinaeli    166 

100  gm.  mashed  potatoes   127 

100  gm.  stewed  apples 53 

60  gm.  toast    154 

4  P.  M. :      120  o-m.  milk  with  tea      81 

30  gm.  crackers     102 

7  P.  M. :       60  gm.  stale  bread   ( 154 )   with  40  gm.  butter   ( 326 )    480 

200  gm.  milk     135 

2456 

Einhom's  diet  for  chronic  gastritis  (first  week)  : 

Calories. 

8  a.m.:  2  eggs 160 

2  ounces  of  fresh  white  bread 156 

4  ounce  of  butter  107 

1  cupful  of  tea  ( 100  gm.  of  tea,  150  gm.  milk)    101 

Sugar,  10  gm 40 

10.30  A.  M. :      Kumiss,  or  milk,  250  gm 168 

Crackers,  30  gm 107 

Butter,  20  gm 163 

12.30  P.  M.:     2  ounces  of  tender  steak  or  white  meat  of  chicken.  ...  72 

Mashed  potatoes  or  rice,  100  gm 127 

White  bread,  2  ounces   153 

Butter,   J  ounce    107 

A  cup  of  cocoa,  200  gm 100 

3.30  P.  M.:      The  same  as  at  10.30  A.  M. 

6.30  P.  ii. :     Farina,  hominy,  or  rice  boiled  in  milk,  350  gm 440 

2  scrambled  eggs   160 

Bread,  2  ounces    156 

Butter,  i  ounce    107 

Total 2863 

The  patient  having  been  kept  on  this  diet  for  a  week  or  two,  it  must 
be  changed  for  one  suitable  to  the  milder  forms  of  chronic  gastritis. 
According  to  Einhorn,  the  diet  should  correspond  as  nearly  as  pos- 
sible to  the  common  mode  of  living.  All  foods  derived  from  the 
vegetable  kingdom  should  be  given  in  large  portions,  while  the  quan- 
tity of  meat  should  be  limited.  It  is  best  rather  to  mention  only  those 
foods  to  be  forbidden  than  to  point  out  a  few  articles  that  can  be 
taken.  Forbid  meat  with  tough  fibers,  meat  that  contains  too  much 
fat,  forbid  sausages,  lobster,  salmon,  chicken  salad,  mayonnaise,  cu- 
cumbers, pickles,  cabbage,  strong  alcoholic  drinks. 

Boas'  diet  for  chronic  gastritis  follows  on  the  next  page: 


DIET  IN  DISEASES  OF  THE  STOMACH  433 

Calories. 

8  o'clock :     200  gm.  milk  and  Hour  soup  ( 100  gm.  milk )    121.5 

50  gm.  bread    129.4 

30  gm.  butter   213.1) 

10  o'clock :          2    eggs    160.0 

50  gm.  white  bread  -|-  30  gm.  butter    343.3 

or  50  gm.  white  bread  -|-  30  gm.  butter  -(-  60  gm.  scraped  beef 

12  o'clock:     200  gm.  farina   milk   soup    227.2 

200  gm.  milk  and  rice 353.4 

100  gm.  prunes     44.0 

3  o'clock:     200  gm.  milk  and  tea  or  milk  and  coffee   (150  gm.  milk)    101.2 

50  gm.  white    bread    120.4 

7  o'clock:     200  gm.  rice  and   milk   soup    335.4 

50  gm.  zwieback     178.0 

2237.6 
Diet  for  chronic  gastritis  (Boas)  : 

Calories. 

8  o'clock :     200  gm.milk  with  40  gm.  cocoa  -|-  30  gm.  sugar   462.0 

50  gm.  cakes  or  50  gm.  zwieback    ( 178.9)    187.0 

10  o'clock  :        50  gm.  bread  with  30  gm.  butter   343.0 

100.  gm.  calf-brain   or    100   gm.    sweetbread    (90)    or    100   gm. 

broiled  rockfish   (71.75)    140.0 

12  o'clock :     Soup  of  30  gm.,  tapioca,  10  gm.  butter  and  1  egg 282.0 

10  gm.  noodles     352.6 

or  100  gm.  spinach  (165.65),  100  gm.  puree  of  beans 
(193),  100  gm.  carrots  (40),  50  gm.  mashed  potatoes 
(63.7) 

100  gm.  breast  of  young  chicken   106.4 

100  gm.  veal   chops    (230),    or    100    gm.    stewed    veal,    pigeon, 
venison,   fish,    100   gm.   farina,   omelet   or   egg,   pancake 

with  ham 288.0 

3  o'clock  :      100  gm.  milk  and  tea  with  28  gm.  sugar 1472 

25  gm.  cakes     93.5 

7  o'clock:       50  gm.  wheat  bread  with  30  gm.  butter 343.0 

50  gm.  scraped  meat    59.5 

2804.2 
DIET  IN  ATROPHIC  CATARRH  OF  THE  STOMACH 

In  conditions  of  atrophy  of  the  gastric  mucous  membrane  there  is 
a  complete  absence  of  the  gastric  secretion.  The  condition  has  also 
been  termed  achylia  gastrica  by  Einhorn.  In  this  disease  the  intes- 
tine acts  vicariously  and  digests  the  food  for  the  stomach.  It  is 
important  to  arrange  the  diet  so  that  it  can  easily  be  acted  upon  by 
the  intestinal  juices.  The  food  must  be  broken  up  into  as  fine  parti- 
cles as  possible,  and  should  to  a  large  extent  be  given  in  liquid  and 
semiliquid  form.  Of  the  liquids,  broths,  such  as  barley,  rice,  or 
chicken  broth,  are  to  be  recommended. 

Vegetables  are  usually  well  borne;  cereals  should  be  eaten  after 
the  cellulose  has  been  removed.  Peas  and  beans  strained  and  eaten 
as  a  puree,  as  in  broth,  are  especially  useful,  as  they  contain  quite  a 
large  percentage  of  protein.  Potatoes  and  rice  are  to  be  eaten  cooked 
with  broth  or  milk,  or  as  a  mush.  Eggs  are  to  be  taken  soft-boiled, 
IMeats  must  be  given  in  the  most  digestible  forms,  as  brains,  scraped 
28 


434  DIET  IN  DISEASE 

beef,  boiled  sweetbreads,  and  only  in  small  amount ;  raw  oysters  and 
boiled  fish  are  also  permissible.  In  very  severe  forms  somatose  and 
Mosquera  Beef  Meal  are  to  be  added  to  the  milk  or  broth.  Milk  is 
occasionally  imperfectly  digested  in  this  condition,  and  cream,  kefir, 
kumiss,  or  matzoon  may  be  substituted  for  it.  Butter  may  be  eaten 
on  crackers,  stale  bread,  or  toast.  Such  beverages  as  tea,  coffee,  cocoa, 
and  small  quantities  of  wine  may  be  allowed. 

Small  meals  should  be  taken  at  intervals  of  two  or  three  hours. 

The  following  diet-list,  advised  by  Wegele,  gives  the  diet  in  atrophic 
catarrh : 

Protein. 

Morning :             1.50  gm.  cocoa    6.00 

Forenoon :  1.50  gm.  wine 

20  gm.  butter  ( on  toasted  bread )   ..  0.15 

100  gm.  maltoleguminose  soup   2.60 

N'oon :                   100  gm.  scraped  beef   20.00 

100  gm.  mashed  potatoes   .3.10 

10  gm.  malt  extract 0.50 

1  cup  tea   (with  zwieback) 

Afternoon :            20  g-m.  butter    0.15 

.30  gm.  honey 0.40 

Evening:              250 gm.  rice     22.00 

Inuring            I       75  gm.  zwieback   (or  toasted  bread)  9.00 

the  day :      T  250  gm.  milk 8.70 

10  o;clock      1      iQ  

at  mght:        j"  ^  « 

Total    72.70 

Calories     300 

Entire  number  of  calories 


Pat. 

Carbohy- 

Alco- 

drates. 

hol. 

4.00 

13.50 

4.00 

12.0 

16.60 

0.12 

0.10 

6.20 

6.00 

0.50 

21.30 
5.50 

16.60 

0.12 
22.00 

8.25 

71.00 

1.50 

63.90 

9.30 

12.00 

7.0 

62.85 

219.64 

19.0 

580 

920 

130 
1930 

Einhorn  "^  advises  the  following  diet  in  cases  of  achylia  gastrica : 

Grams.      Calories. 

8  A.  M. :           Oatmeal  with  cream   150  395 

Cocoa  with  milk    200  135 

Toasted  bread     60  135 

Butter     20  163 

12  M. :              Pea  soup    200  190 

Scraped  meat    (broiled)   or  fish   100  213 

Baked  or  mashed  potatoes 50  63 

Spinach  or  turnips   50  82 

Wheaten  bread   60  135 

Butter     20  163 

6. P.M.:           Two  eggs   (soft-boiled)  or  scrambled  ....  160 

Farina  with  milk    200  432 

Wheaten    bread    60  135 

Butter     20  163 

Tea   (milk  and  sugar)    240  60 

9.30  P.  M. :     Kumiss     -.  200 

Crackers     30 

Butter     10 

or  a  sandwich  with  cream  or  caviare.  .  .  323 


2947 
1  Diseases  of  Stomach,  p.  384. 


7 

A. 

M. 

9 

A. 

M. 

2 

jr 

3 

p. 

M. 

6 

p. 

M. : 

DIET  IJSi  DISEASES  OF  TEE  STOMACH  435 

Diet  in  achylia  gastrica  (Zweig)  : 

T,     I  •  ,-,>  ..  .,,  Calories. 

Early  morning:     2o0  c.e.  ot  cocoa  in  milk,  3  zwieback,  10  gm.  butter 466 

Forenoon:  Flour  soup  with  1  egg,  2.)  gm.  toast,  20  gm.  butter 371 

Noon:  Leguminous    soup    with    1    egg,    130   gm.    scraped    beef,    50 

gm.  vegetable  puree,  250  gm.  milk,  25  gm.  toast,  20  gm. 

butter     765 

Afternoon :  Same  as  early  morning   466 

Evening:  2   soft-boiled   eggs,   200   gm.    rice  or   farina   with   milk,   25 

gm.  toast,  20  gm.  butter   822 

On  retiring:  250  gm.  milk 170 

Total     3060 

Eisner  advises  the  following  diet  in  chronic  anacid  gastritis  and  in 
achjlia  gastrica : 

Soup,  milk,  or  cocoa,  wlieat  bread  or  toast  with  butter,  and,  in  case 

of  constipation,  marmalade  or  honey. 
Wheat  l)read,  or  toast  with  butter,  cold  roast,  beer,  or  white  or  red 

wine. 
Bouillon   puree  of  vegetables,   mashed   potatoes,   boiled   fisli   or  boiled 

meats,  white  meat  of  fowl. 
Cocoa  or  tea,  wheat  bread  or  zwieback  or  light  cake. 
Kice  or  farina,   puree  of  vegetal)les,  wlieat   bread,   butter,  cold  sliced 

meats,  beer  or  wine,  or  mineral  water. 

Eisner  calls  attention  to  the  uselessness  of  eggs  in  this  disorder  in- 
asmuch as  egg-albumin  remains  undigested  in  the  intestines,  due  to 
the  marked  antitryptic  action  of  egg  white. 

DIET  IN  HYPERSECRETION 

By  hypersecretion  is  meant  a  continuous  excessive  secretion  of  gas- 
tric juice ;  the  condition  may  be  intermittent  or  chronic. 

In  intermittent  hypersecretion  the  excessive  secretion  occurs  peri- 
odically and  is  accompanied  by  extreme  distress.  This  distress  may 
often  be  lessened  if  a  small  quantity  of  milk  or  a  hard-boiled  egg  is 
taken  at  the  very  beginning  of  an  attack.  Inasmuch  as  fluids  in  large 
quantities  tend  to  increase  the  vomiting,  their  use  should  be  pro- 
hibited. If  thirst  is  severe,  small  bits  of  ice  may  be  given  or  rectal 
injections  administered.  The  diet  during  the  interval  between  at- 
tacks is  similar  to  that  prescribed  in  hyperchlorhydria  (g.v.). 

Chronic  Hypersecretion. — In  this  condition  an  excessive  quantity 
of  gastric  juice  is  secreted  continuously.  In  the  treatment  of  this 
disorder  all  foods  that  tend  to  increase  the  secretion  of  acid  in  the 
stomach,  such  as  spices,  condiments,  and  stimulants,  are  to  be  pror 
scribed.  The  diet  should  be  made  up  largely  of  the  proteins,  since 
these  foods  are  generally  well  borne;  the  carbohydrates  are  poorly 
digested,  and  hence  must  be  given  only  in  small  quantities  and  in  the 
most  readily  assimilable  forms.  Inasmuch  as  fats  diminish  the  secre- 
tion of  hydrochloric  acid  they  may  be  used  to  advantage  in  hyper- 
secretion.    Fluids  should  be  administered  sparingly.     Food  should  be 


436  DIET  IN  DISEASE 

given  at  intervals  of  two  or  three  hours.  All  forms  of  meats  are 
allowable — chicken,  roast  beef,  lamb  chops,  broiled  steak;  "the  meats 
being  thoroughly  cooked  in  order  to  avoid  the  effect  of  the  extractives 
which  tend  to  further  increase  the  gastric  secretion,"  Of  carbo- 
hydrates, the  best  are  oatmeal,  zwieback,  and  Nestle 's  food ;  puree  of 
potatoes,  spinach,  etc.,  may  also  be  eaten.  Milk  is  an  excellent  food 
in  this  disease,  and  may  be  taken  either  alone  or  mixed  with  tea, 
coffee,  cocoa,  or  eggs.  In  aggravated  forms  of  the  disorder  Riegel 
advises  an  exclusive  milk  diet  for  about  eight  days ;  the  milk  produc- 
ing a  sedative  effect  upon  the  gastric  mucous  membranes,  reducing 
the  secretion  of  gastric  juices.  The  same  effect  may  be  obtained 
at  first  by  exclusive  rectal  feeding  for  a  period  of  six  or  eight  days. 

Diet-list  for  Hypersecretion   (after  Wegele) . 

Protein.         Fat.      Carbohy- 

Morning:             100  gm.  tea  with  milk    3.4  3.0           4.8 

2  soft-boiled  eggs   12.0  10.0 

Forenoon:            150  gm.  calf  s-foot  jelly    35.0  17.0           1.0 

Noon:                   150  gm.  sweetbread  in  bouillon 32.0 

250  gm.  tapioca  mush    12.0  8.0         11.0 

50  gm.  cream   2.0  13.5           1.7 

Afternoon :          200  gm.  milk    6.8  6.0           9.6 

Evening :              200  gm.  ham     48.0  70.0 

2  scrambled   eggs    12.0  12.0 

At  meal  times:   100  gm.  aleuronat  toast    28.3  1.5         66.7 

lO^;^-.,,       l^!^^""!!:   1 6.5  6.0         10.0 

During  night :     100  gm.  milk    J 

Total     198.0       147.0       104.8 

Calories    900        1360  430 

Entire  number  of  calories 2700 

The  authors  have  prescribed  the  following  diet  in  hypersecretion 
of  gastric  juice: 

Calories. 

8  A.  M. :     200  gm.  milk  flavored  with  tea   135 

2  soft-boiled   eggs    160 

60  gm.  toast   154 

40  gm.  butter    326 

10  A.  M. :       50  gm.  raw  scraped  beef    60 

50  g-m.  toast 130 

12  M. :      100  gm.  broiled  steak    210 

or  100  gm.  chicken  or  lamb  chop 

100  gm.  asparagus      18 

or  100  gm.  of  carrots  (41)  mashed  and  strained, 
or  100  gm.  of  peas  (318)  mashed  and  strained, 
or  100  gm.  spinach    ( 165 ) 

100  gm.  stale  wheat  bread    258 

4  P.  M. :     200  gm.  milk     135 

1  soft-boiled  egg    80 

60  gm.  toast    154 

40  gm.  butter     326 

7  P.  M. :      100  gm.  baked  trout    106 

100  gm.  milk     67 

2319 


DIET  IN  DISEASES  OF  THE  STOMACH  437 

DIET  IN  DILATATION  OF  THE  STOMACH 

In  the  dietetic  treatment  of  dilatation  of  the  stomach  it  must  be 
remembered  that  the  least  possible  demand  should  be  made  upon  the 
motor  function  of  the  stomach,  and  inasmuch  as  fluids  are  badly 
borne  must  therefore,  be  given  only  in  very  small  quantities — not  over 
one  to  one  and  one-half  liters  a  day.  The  fluids  that  are  permissible 
are  milk,  cream,  cocoa,  coffee,  tea,  and  bouillon,  all  in  small  quantities. 
The  thirst  that  accompanies  this  disease  may  be  relieved  by  allowing 
the  patient  to  suck  bits  of  ice  or  by  giving  rectal  injections  of  water 
or  normal  salt  solution,  administered  by  the  drop  method.  Since 
nutrition  is  usually  very  faulty  in  this  disease,  nutrient  enemata  must 
frequently  be  employed.  The  patient  may  be  given  one  to  two  ounces 
of  pure  olive  oil.  The  oil  not  only  exerts  an  antispasmodic  action  but 
tends  to  diminish  the  gastric  secretion.  When  milk  is  administered, 
such  substances  as  tapioca  and  rice  should  be  added.  Egg  or  con- 
centrated meat-extracts  should  be  added  to  bouillon  to  increase  its 
nutritive  value.  j\Ieats  should  be  given  only  in  the  most  digestible 
forms;  of  these,  stewed  chicken,  boiled  sweetbreads,  calves '-brains, 
and  scraped  beef  are  to  be  preferred.  Vegetables,  such  as  carrots, 
spinach,  peas,  potatoes,  should  be  administered  in  the  form  of  purees. 
Bread  should  be  eaten  stale;  wheat  bread  or  toast  is  best.  Stewed 
fruits,  such  as  stewed  prunes  and  baked  apples,  are  also  permissible. 
Since  fats  are  apt  to  cause  fermentation,  butter  should  be  allowed  only 
in  quite  small  quantities.  Alcohol  is  not  to  be  recommended  in  this 
condition ;  if  it  must  be  used,  it  is  best  given  in  the  form  of  some 
light  wine.  Strong  spices  should  always  be  avoided.  The  use  of 
olive  oil  in  the  treatment  of  dilatation,  as  has  been  advocated  by 
Cohnheim,  has  already  been  described. 

The  special  feature  of  the  treatment  is  small  quantities  of  food, 
given  frequently  in  a  semifluid  form.  It  is  unwise  to  prescribe  an 
absolute  dry  diet,  as  was  formerly  advised  in  the  treatment  of  this 
condition.  Patients  with  dilatation  of  the  stomach  should  be  cau- 
tioned against  visiting  watering  places. 

The  following  is  the  diet-list  used  by  the  authors  in  dilatation  of  the 
stomach : 

Calories. 

8  A.  M. :     100  gm.  milk  with  tea   67 

50  gm.  stale  wheat  bread    130 

10  gm.  butter    80 

1  egg    80 

10  A.  M. :      100  gm.  raw  scraped  beef    118 

50  gm.  toast    130 

10  gm.  butter    80 

50  c.c.  sherry   wine    60 

12  M. :      150  gm.  broiled  steak    315 

or  150  gm.  lamb  chops  or  chicken 

100  gm.  baked   potatoes    127 

100  gm.  spinach      166 


438 


DIET  IN  DISEASE 


4  P.  M. 


t    P.  M. 


or  100  gm.  asparagus    ( 185 ) 

or  100  gm.  peas,  mashed  and  strained   (318) 

or  100  gm.  carrots,  mashed  and  strained  (41) 

100  gm.  cieam    214 

50  gm.  stale   bread    130 

1 0  gm.  butter 80 

100  gm.  boiled   rock   tish    80 

50  gm.  stale  wheat   bread    130 

10  gm.  butter    80 


Boas'  Diet-list  in  Dilatation  of  the  Stomach. 

8  A.M.:      100  gm.  tea    and    milk    (saccharin,    not    sugar)    with    50   gm. 

toasted  bread    

10  A.  M. :      100  gm.  flour     

30  gm.  toasted  bread    (77.70)  +  10  gm.  butter    (71.30) 

12  M. :  150  gm.  broiled  meat   

25  gm.  mashed   potatoes    

or   50   gm.   spinach    (S2.3),   50   gm.   carrots    (20.5),   or 
puree  of  beans    (96.5) 

2  P.  M. :       50  gm.   cream    

4  P.M.:      100  gm.  tea   witli   milk    (saccharin,   not   sugar),   with   50   gm. 

toasted    bread    

7  P.  M. :      100  gm.  broiled   perch    

50  gm.  wheat  bread   ( 129.00)  +  10  gm.  butter   (71.30) 

100  gm.  cream      

9  P.  M. :        50  gm.  cream      


2067 

Calories. 

195.D0 
437.00 
149.00 
320.70 
63.70 


107.30 

195.50 
71.75 
200.30 
214.00 
162.30 


Morning : 
Forenoon : 

Noon: 

Afternoon : 
Evening : 

During  the 

day: 
Night: 


Total    2117.05 

Wegele's  Diet-list  for  Dilatation  of  the  Stomach. 

Protein. 

100  gm.  scraped  ham   25.0 

Tea  with  50  gm.  cream 1.8 

2  eggs   12.0 

20  gm.  sugar    

20  gm.  cognac    

100  gm.  scraped  beef    20.7 

100  gm.  mashed  potatoes    3.8 

Tea  with  50  gm.  cream   1.8 

100  gm.  roast  chicken  (hashed)  ..  20.7 
100  gm.  flour   (puff  paste)    4.2 

»  80  gm.  zwieback    8.^ 


200  gm.  milk 


6.4 


Fat. 

Carbo- 

Alco- 

hydrates. 

hol. 

8.0 

13.3 

1.8 

10.0 

16.0 

13.8 

1.5 

0.5 

21.3 

13.3 

1.8 

1.5 

4.3 

22.0 

1.2 

55.0 

7.2 

9.6 

Total     104.2         60.8       127.5         13.8 

Calories 427.0       565.0       722.0  100 

Entire  number  of  calories   1600 


Biedert's  Diet-list  for  Dilatation  of  the  Stomach. 

Protein.  Fat. 

6  A.  M. :     500  gm.  milk,  40  gm.  toast 20.3  18.4 

8  A.M.:     Oatmeal  soup  with  15  gm.  of  meat  solution..        5.5  1.0 
10  A.M.:     Cream  mixture   (125  c.c.  of  cream  and  6  gm. 

of  lactose) ,  40  gm.  toast   7.8  12.9 

12. M.:         Barlej"  soup  with  yolk  of  1  egg 4.0  9.2 

140    gm.    of     roast     beef,    venison,     poultry, 

boiled  chopped  beef,  or  fish  42.8  10.4 


Carbo- 
hydrates. 

55.8 
14.2 

41.5 

■  7.7  _ 


DIET  IN  DISEASES  OF  THE  STOMACH  439 


40  gm.  toast   '3.3  0.4         30.8 

25  gm.     cinnamon    cake,     soda    cake,     collee 

cake,  biscuit,  small  cup  black  coffee 2.0  1.5         14.0 

4  P.M.:      250    c.c.    of    milk,    water,    or    cocoa,    3    zwie- 
back  (30  gm.) 9.2         11.3         38.3 

7  P.M.:     Leguminose  soup  with   15  gm.  of  meat  solu- 
tion   or    soup    made    from    ^    timpe    soup 

lozenge     " 7.G  1.0  12.6 

Rice  flour  mush   18.3         14.1         98.1 

120.8         80.2       313.0 
Total  value,  about  2524  calories. 

Biedert's  Diet-list  for  Dilatation  of  the  Stomach. 
(More  Nourishing  than  the  Preceding  List) 

Protein.        Fat. 


Carbo- 
hydrates. 


6  a.m.:     250  c.c.  milk,  30  gm.  toast  11.0  9.3  35.6 

8  A.  M. :          2  eggs,  20  gm.  of  toast  13.7  10.2  15.4 

10  A.  m.:      125  c.c.  cream,  2  zwieback   6.9  14.0  18.8 

12  M. :  140  gm.  roast  beef,  venison,   poultrv,   chopped 

beef,  or  fish    ". 42.8  10.4 

40  gm.  toast   3.3  0.4  30.8 

25  gm.  soda     cake,     cinnamon     cake,     coffee 

cake,    biscuit 2.0  1.5  14.0 

4  P.M.:     250  c.c.  milk-cocoa,  3  zwieback  with  fruit  jelly  13.5  15.8  44.6 

7  p.  M. :     Rice  mush,  2  zwieback,  cakes   14.8  10.8  78.7 

10  p.m.:     250  c.c.  milk,  2  zwieback   10.9  10.5  26.3 

118.9         82.9       264.2 
Total  value,  about  2341  calories. 

Diet  in  Dilatation  of  the  Stomach   with  Anacidity — {After  Zioeig) . 

Early  morning:   lavage  of  stomach. 

Calories. 

8  A.  M. :     250  gm.  rice,  30  gm.  toast  or  zwieback 278 

10  A.  M. :     2  eggs,  20  gm.  zwieback    235 

1-2  M. :         Leguminous  soup  of  20  gm.  legumes  and  1  egg.  .  .  .    135 
1.30  P.M.:      100    gm.    poultry,    calves'    brains,    sweetbreads,    or 
fish,   50  gm.   vegetables,  20  gm.   toast,    100  gm. 

milk   336 

4  P.  M. :     250  gm.  cocoa  with  milk,  3  zwieback 385 

6  P.  M. :     Tapioca    pudding    ( 250   gm.   milk,    20   gm.    tapioca, 

15   gm.   sugar)       300 

8  P.M.:      50  gm.  scraped  beef  omelet   (2  eggs,   10  gm.  sugar, 

10  gm.  butter )    350 

9.30  P.M.:     20  gm.  toast   (150  gm.  milk  with  30  gm.  zwieback)    287 

Total    2302 

DIET  IN  ATONY  OF  THE  STOMACH 

Since  atony  is  frequently  cau.sed  by  injudicious  and  too  rapid  eat- 
ing, persons  with  feeble  digestive  powers  should  exercise  especial  cau- 
tion to  eat  slowly,  masticate  thoroughly,  and  avoid  indigestible  food. 
Persons  suffering  from  atony  of  the  stomach  should  eat  small  quan- 
tities of  food  at  frequent  intervals.  Since  water  is  not  absorbed  in 
the  stomach  to  any  extent,  it  is  advisable  that  the  quantity  of  fluids 


440  DIET  IN  DISEASE 

taken  should  not  exceed  II/2  liters  a  day ;  this  amount  should  include 
all  fluids — coffee,  tea,  soups,  etc.  If  the  thirst  is  very  great,  enemata 
of  water  or  nutrient  enemata  may  be  administered. 

The  use  of  milk  in  large  quantities,  as  has  been  recommended,  is 
not  generally  to  be  advised  when  the  patient  is  able  to  go  about, 
since  the  weight  of  large  quantities  of  milk  may  overdistend  the 
stomach ;  when,  however,  a  rest  cure  is  instituted,  milk  is  commonly 
well  borne  when  taken  in  moderate  quantities  (250  c.c.)  at  frequent 
intervals.  The  diet  in  atony  of  the  stomach  varies  according  to  the 
nature  of  the  gastric  secretion.  In  cases  of  superacidity  a  liberal 
meat  diet,  consisting  especially  of  chicken,  beef,  mutton,  or  ham,  is 
to  be  recommended;  fish,  eggs,  hard  and  soft  boiled,  are  also  per- 
missible ;  the  vegetables  should  be  selected  with  care ;  carrots,  peas, 
beans,  and  cauliflower  may  be  given,  but  must  be  mashed  and  strained 
so  as  to  rid  them  of  cellulose ;  potatoes,  rice,  and  grits  may  also  be 
allowed.  Butter  is  the  form  of  fat  best  suited  to  this  condition. 
Alcoholic  stimulants  are,  as  a  rule,  not  well  borne,  and  their  use 
should  be  prohibited ;  in  a  limited  number  of  cases  alcohol  in  the  form 
of  a  light  wine  acts  as  a  stomachic,  and  may  be  prescribed. 

The  following  list  has  been  used  by  the  authors  in  the  treatment  of 
atony  of  the  stomach  : 

Calories. 

7  A.  M.       40  gm.  orange-juice 88 

8  A.  M. :     200  gm.  milk     135 

1  soft-boiled   egg    80 

60  gm.  toast    154 

40  gm.  butter    .325 

10  A.  M. :      100  gm.  raw  scraped  beef    118 

60  gm.  stale  wheat  bread 154 

12  M. :      100  gm.  broiled  steak    209 

or  100  gm.  lamb  chops   (230) 
or  100  gm.  stewed  chicken   ( 106) 

200  gm.  asparagus    37 

or  100  gm.  peas    (318) 
or  100  gm.  spinach   ( 165 ) 

100  gm.  mashed  potatoes   127 

100  gm.  apple-sauce 53 

50  gm.  bread    (stale)     130 

3  p.m.:     200  g-m.  milk     135 

60  gm.  wheat   bread    154 

40  gm.  butter     325 

7  P.  M. :      100  gm.  boiled   rock    fish    80 

100  gm.  milk     67 

60  gm.  bread    154 

40  gm.  butter    325 

2850 

In  those  cases  in  which  there  is  an  absence  or  a  diminution  of  acid 
in  the  gastric  secretion  the  lighter  forms  of  meat,  such  as  the  white 
meat  of  chicken  or  fish,  sweetbreads,  stewed  chicken,  or  raw  scraped 
beef,  should  be  allowed ;  vegetables,  on  the  other  hand,  must  be  given 


DIET  IS  DISEASES  OP  THE  STOMACH 


441 


iu  somewhat  larger  quantities.  The  treatment  of  the  chronic  con- 
stipation accompanying  gastric  atony,  since  it  is  one  of  the  most 
constant  symptoms,  requires  special  mention.  In  the  treatment  of 
this  condition  the  main  reliance  must  be  placed  on  the  diet.  Such 
forms  of  foods  should  be  given  as  will,  in  the  course  of  digestion, 
produce  substances  that  excite  intestinal  peristalsis ;  among  these 
foods  may  be  mentioned  Graham  bread,  certain  vegetables,  such  as 
carrots,  beans,  tomatoes,  peas,  and  turnips,  macaroni,  stewed  and 
raw  fruits,  buttermilk,  honey,  and  cider.  This  form  of  diet  will 
often  overcome  the  constipation  of  atony  without  the  aid  of  drugs. 
(For  a  more  extensive  consideration  of  the  dietetic  treatment  of 
chronic  constipation  the  reader  is  referred  to  the  section  dealing  with 
this  subject.) 

Diet-list  in  Atony  of  Stomach   with  Eypochlorhydria — ■{After   Wegele). 

Carbo-       Alco- 
Protein.      Fat.       hydrates,     hoi. 

Morning:                       150  gm.  leguminose  cocoa   ....  6.0  4.0  13.5 

50  gm.  cream    1.8  13.3  1.8 

Forenoon:                         1  soft-boiled  egg   6.0  5.0 

20  gm.  zwieback 2.5  0.4  15.0 

Xoon :                            100  gm.  scraped  beef 17.1  6.0 

200  gm.  mashed  potatoes 4.2  2.7  42.6 

20  gm.  malt  extract    1.0  ...  11.0 

Afternoon:                   150  gm.  leguminose  cocoa   ....  6.0  4.0  13.5 

50  gm.  cream    1.8  13.3  1.8 

Evening:                      250  gm.  tapioca    pulp     12.0  8.0  11.0 

15  gm.  diastase  malt  extract.  0.8  ...  9.0 

During  the  day :            50  gm.  zwieback 6.0  1.0  35.0 

10  o'clock  at  night:  200  gm.  milk     6.4  7.2  9.6 

10  gm.  cognac ...  ...          6.9 

Total   71.6         64.9       163.8         6.9 

Calories     290  600  670  50 

Entire  number  of  calories    1600 

Diet-list  in  Atony  of  the  Stomach  with  Hyperchlorhydria  and  formal 
Acidity — (After  Wegele). 

^  Carbo-        Alco- 

Protein.       Pat.        i,   j     ,.  i,„i 

bydrates.       nol. 

Morning:                150  gm.  peptone  cocoa   8.0  6.0  7.5 

50  gm.  cream    1.8  13.3  1.8 

Forenoon :                30  gm.  milk-toast    3.0  0.2  20.0 

50  gm.  ham     12.5  4.0 

1  egg    6.0  5.0 

Noon :                      120  gm.  roast  meat 21.0  8.0 

200  gm.  mashed  potatoes 4.2  2.7  42.6 

Afternoon:             150  gm.  peptone  cocoa   8.0  6.0  7.5 

50  gm.  cream    1.8  13.3  1.8 

Evening:                120  gm.  cold  roast  meat 21.0  8.0 

200  gm.  rice   9.0  6.6  28.6 

10  o'clock:              100  gm.  wine    3.3         7.8 

During  the  day :      50  gm.  zwieback    6.5  1.6  41.0 

Total  102.8         74.7        159.1         7.8 

Calories     420  700  640  55 

Entire  number  of  calories    1800 


442  DIET  IN  DISEASE 

Diet-list  for  Atony  of  the  Stomach,  as  advised  by  Boas. 

Calories. 

6  A.  M. :      100  gm.  milk  and  tea,  50  gm.  wheat  bread,  30  gm.  butter 401.2 

(in  constipation,  50  gm.  milk) . 

10  A.  M. :       50  gm.  wheat  bread,  50  gm.  butter   343.7 

60  gm.  scraped  meat,  raw   71.5 

or  broiled   (128.3),  or  60  gm.  ham   (262.2) 

12  M. :  150  gm.  cooked  beef,  and  50  gm.  macaroni   439.3 

(or  100  gm.  rice,  farina,  mashed  potatoes) 
3  P.  M. :      100  gm.  milk  and  tea,  50  gm.  wheat  bread,  30  gm.  butter 401.2 

7  P.  M. :      100  gm.  cold   beef 213.8 

50  gm.  wliite  bread,  30  gm.  butter   343  7 


2214.4 
DIET  IN  TILCEE  OF  THE  STOMACH 

Propliylactieally  much  can  be  done  by  a  carefully  selected  diet 
to  prevent  the  onset  of  an  ulcer  of  the  stomach.  As  soon  as  the  very 
first  symptoms  become  manifest,  the  patient  should  be  placed  upon 
an  absolute  milk  diet.  The  temperature  of  the  food  should  be  regu- 
lated, so  that  it  be  not  given  too  hot  or  too  cold.  Anemia,  which  so 
frequently  accompanies  the  disease,  must  be  combated;  hyperchlor- 
hydria,  which  is  so  important  an  etiologic  factor  in  this  condition, 
must  also  be  overcome.  Rosenow's  recent  work  suggests  the  proba- 
bility of  focal  infection  with  special  strains  of  streptococci  as  a  cause 
of  peptic  ulcer  in  many  instances.  On  this  account  it  is  highly  im- 
portant before  instituting  treatment  to  remove  as  far  as  possible  all 
sources  of  local  infections,  such  as  peridental,  tonsillar,  appendicular, 
gall-bladder  and  infections  of  any  other  of  the  organs  of  the  body. 
While,  however,  infection  is  a  probable  etiological  factor,  it  has  by 
no  means  been  proved  that  it  is  the  sole  factor  in  the  causation  of 
this  disease. 

Boas  ^  divides  the  treatment  of  ulcer  of  the  stomach  into  several 
stages : 

Stage  of  Hemorrhage. — In  this  stage  Boas  advises  absolute  rest  in 
bed;  the  patient  not  being  even  allowed  to  arise  for  purposes  of  de- 
fecation or  urination.  No  nourishment  whatever  should  be  given  by 
the  mouth.  In  robust  individuals  even  nutrient  enemata  may  be 
omitted.  If  the  patient  is  weak  or  in  feeble  condition,  feeding  by  the 
rectum  may  be  instituted.  (See  the  section  on  Nutrient  Enemata 
for  the  method  of  preparation  and  utilization  of  this  mode  of  feed- 
ing.) Only  two  or  three  nutrient  enemata  are  to  be  given  daily. 
Boas  carries  out  this  plan  for  three  or  four  days.  After  this  he 
gradually  begins  mouth-feeding,  the  nourishment  consisting  exclu- 
sively of  milk  diluted  with  lime-water,  with  tea,  or  with  coffee.  He 
begins  usually  with  300  gm.  a  day  (20  gm.  every  hour),  and,  if  pos- 
sible, increases  100  gm.  a  day,  so  that  on  the  seventh  day  the  patient 
consumes  1  liter;  on  the  tenth,  li/4  to  2  liters;  and  on  the  fifteenth, 

1  Magenkrankheiten,  p.  407. 


DIET  /A   DISEASES  OF  THE  STOMACH  443 

21/^  to  3  liters.  A  third  cream  may  be  added  to  the  milk  very  early 
in  the  treatment.  In  addition  he  permits  beef-tea,  freshly  expressed 
or  artificial  beef-juice,  and  egg-albumin.  The  carbonated  waters,  such 
as  Mchy,  are  also  useful. 

After  the  tirst  week  Boas  begins  the  regular  Leube  and  Ziemssen 
ulcer  treatment,  which  he  conducts  as  follows:  The  patient  is  given 
1/4  liter  of  Carlsbad  water,  which  he  drinks  in  bed  morning  and  eve- 
ning. Hot-water  applications  are  placed  on  the  abdomen.  The  diet 
during  this  stage  consists  mainly  of  milk  in  addition  to  other  fluids, 
as  cream,  egg-albumin,  and  even  raw  eggs.  If  the  patient  is  very 
weak,  nutrient  enemata  may  occasionally  be  given. 

In  the  treatment,  beginning  with  the  third  and  continuing  during 
the  fourth  week,  Boas  permits  the  patient  to  recline  on  a  couch,  and 
continues  the  use  of  the  Carlsbad  water,  which  should  be  ^ven  for 
four  weeks  from  the  time  it  is  first  taken ;  he  advises  that  the  diet 
still  consists  mainly  of  milk,  although  he  now  permits  the  addition  of 
soaked  zwieback,  scalded  crackers,  and  soft  rolls.  Meats  (sweetbreads, 
brains,  meat  balls K  fish  (perch,  oysters  in  small  quantities),  in  addi- 
tion to  the  light  red  wine  and  carbonated  waters,  are  also  allowed. 

After  the  fourth  week,  if  the  patient  is  doing  well.  Boas  adds  from 
50  to  200  gm.  of  mashed  potatoes,  stewed  fruits,  and  vegetables,  such 
as  spinach,  carrots,  peas,  and  turnips,  in  the  form  of  purees,  to  the 
diet  previously  given.  The  meats — broiled  steak,  chops,  and  roast 
beef — if  well  cooked,  can  finally  be  given  more  liberally.  According 
to  Boas,  the  patient  should  avoid  raw  fruit,  acid  and  highly  seasoned 
foods,  and  also  very  hot  and  very  cold  drinks,  for  many  years.  Even 
in  those  eases  in  which  there  has  been  no  hemorrhage  Boas  neverthe- 
less advises  the  rest  treatment.  It  is  generally  admitted  that  the  rest 
cure  is  the  only  satisfactory  plan  for  treating  cases  of  ulcer  of  the 
stomach.  Leube  and  Penzoldt  have  devised  dietaries  for  these  cases; 
these  have  been  given  elsewhere  (see  pp.  413,  418).  The  first  dietary 
should  be  followed  for  ten  days ;  the  second,  for  the  succeeding  ten 
days ;  the  third,  for  about  eight  days.  The  severity  of  the  condition 
in  each  case  must,  of  course,  determine  the  length  of  time  during 
which  each  dietary  must  be  continued.  In  all  instances  milk  seems 
to  be  the  most  useful  form  of  food  during  the  first  weeks  of  this  rest 
treatment.  This  plan  was  carried  out  many  years  ago  by  Cruveilhier 
in  his  treatment  of  ulcer  of  the  stomach.  Occasionally  milk  does 
not  agree,  and  substitutes  must  be  given  in  its  stead.  Of  these,  butter- 
milk, kefir,  matzoon,  kumiss,  or  yoghurt  are  especially  to  be  recom- 
mended. In  order  to  increase  the  food-value  of  milk,  cream  may  be 
added,  and  the  following  calculation  of  Strauss  may  be  utilized  in 
order  to  estimate  this  increased  value : 

Calories. 

A.  100  gm.  full  milk   70 

B.  75  gm.  full  milk  with  25  gm.  cream   115 


444  DIET  IN  DISEASE 

Calories 

C.  50  gm.  full  milk  with  50  gm.  cream 185 

D.  25  gm.  full  milk  with  75  gm.  cream   205 

E.  180  gm.  cream   250 

There  are,  therefore,  of  each  (milk,  milk  and  cream,  and  cream)  in 
the  half  liter: 

Calories. 

A 350 

B 575 

C 925 

D 1025 

E ; 1250 

Among  other  preparations  that  have  been  found  useful  as  foods 
are  the  well-known  Leube-Rosenthal  beef  solution,  as  recommended 
by  Leube  and  Rosenthal,  and  chicken  and  calves '-foot  jelly,  as  ad- 
vised by  Fleiner. 

In  those  cases  in  which  milk  is  not  well  borne  Debove  suggests 
that  the  milk  be  passed  into  the  stomach  through  the  stomach-tube. 
He  found  that  when  given  in  this  way  the  milk  was  not  vomited. 
Bouveret  also  recommends  this  mode  of  feeding  in  intractable  cases 
of  ulcer. 

There  are  a  number  of  cases  of  ulcer  of  the  stomach  that  do  not 
yield  to  the  ordinary  rest  treatment  as  outlined  by  Boas,  Leube,  and 
Penzoldt.  Doiikin  ^  tirst  directed  attention  to  the  fact  that  excellent 
results  could  be  obtained  in  this  class  of  cases  by  exclusive  rectal 
alimentation.  His  treatment  extended  over  twenty-three  days;  since 
then  McCall  Anderson  -  and  Boas  ^  have  obtained  excellent  results  by 
this  plan  of  treatment  in  obstinate  and  recurrent  cases  of  ulcer  of 
the  stomach;  Riegel,  too,  approves  of  this  plan.  Boas  carries  out 
exclusive  rectal  alimentation  for  at  least  ten  days;  he  then  allows 
fluids,  such  as  milk,  tea,  bouillon,  red  wine,  for  some  days,  and  finally 
permits  the  patient  to  resume  his  usual  diet.  We  have  found,  in 
administering  nutrient  enemata  in  this  condition,  that  far  better 
results  are  obtained  when  the  enemata  are  given  by  the  continuous- 
drop  method  of  Murphy  at  the  rate  of  about  60  drops  per  hour  or 
less.  They  are  far  better  retained,  and  give  rise  to  less  irritation  to 
the  rectum.  Most  patients  can  retain  several  quarts  of  milk  a  day 
with  four  to  six  raw  eggs  without  difficulty,  providing  the  milk  and 
eggs  are  kept  warm  so  as  not  to  coagulate  in  the  tube.  When  the 
patient  is  greatly  reduced  in  strength,  the  caloric  value  of  the  nutrient 
enema  may  be  enhanced  by  the  addition  of  1  to  2  drams  of  grape- 
sugar. 

There  are  a  certain  number  of  light  forms  of  ulcer  of  the  stomach 
in  which  it  is  impossible  to  carry  out  the  rest  treatment.     In  such 

1  Lancet,  1890. 

2  Brit.  Med.  Jour.,  1890. 

3  Magenkrankheiten,  p.  59. 


i 


DIET  ly  DISEASES  OF  THE  STOMACH  445 

cases,  at  times,  Boas  advises  an  ambulatory  treatment,  together  with 
the  use  of  silver  nitrate.  The  silver  is  administered  in  solution  on 
an  empty  stomach  in  from  %-  to  ^-2-grain  doses;  at  the  same  time  a 
carefully  regulated  diet  is  given.  The  food  consists  chiefly  of  milk 
and  other  fluids ;  in  addition  he  allows  tender  meats  and  fish,  mashed 
potatoes,  and  vegetables  in  the  form  of  purees  (cautiously),  all  in 
moderate  quantities. 

Cohnheim  advises  the  use  of  olive  oil  in  the  treatment  of  gastric 
ulcer,  and  claims  that  cases  of  ulcer  associated  with  or  without 
hyperchlorhydria  are  quickly  cured  by  means  of  the  oil  treatment  or 
by  an  emulsion  of  sweet  almonds.  Bloch  has  also  reported  great 
benefit  from  small  doses  of  oil.  The  oil  is  given  before  meals,  be- 
ginning with  a  few  spoonsful  and  increasing  to  a  wineglassful  or  more 
before  each  meal.  If  disgust  is  produced  by  the  oil,  its  use  must  be 
abandoned,  or  the  oil  of  sweet  almonds  may  be  utilized  in  its  stead. 
With  this  sweet  oil  the  associated  treatment,  such  as  diet,  rest,  etc., 
must  be  carried  out. 

Mineral  waters  are  often  utilized  in  the  treatment  of  ulcer  of  the 
stomach ;  of  these,  Carlsbad  waters  have  been  especially  recommended, 
but  Saratoga  (Hathorn)  can  also  be  used  with  benefit.  The  mineral 
water  treatment  should  be  undertaken  only  at  the  spring,  after  the 
ulcer  has  healed,  and  after  the  patient  has  undergone  the  rest  cure. 
The  treatment  at  Carlsbad  or  Saratoga  will  often  prevent  the  pos- 
sibility of  relapses.  After  the  ulcer  has  healed,  it  is  important  to 
overcome  the  anemia  which  is  usually  present  in  most  cases  of  gastric 
ulcer.  This  may  be  accomplished  by  means  of  the  diet  (see  Diet  in 
Anemia)  as  well  as  by  sending  the  patient  to  some  invigorating 
watering-place  or  to  the  mountains.  Iron  and  arsenic  should  also  be 
given  to  overcome  this  condition.  They  should  not,  however,  be  pre- 
scribed until  the  ulcer  is  healed. 


DIET-LISTS  OF  WEGELE  FOR  ULCER  OF  THE  STOMACH 
Diet  I — To  be  followed  at  least  ten  days. 

Protein. 

Morning:  250  gm.  milk     8.50 

2  cakes   (5  gm.  each)    1.10 

10  o'clock :       250  gm.  milk 8.50 

1  cake    0.60 

12  o'clock :       150  gm.  bouillon     0.75 

50  gm.  meat  solution   (or  egg)    8.50 

4  o'clock :       250  gm.  milk     8.50 

2  cakes     I.IO 

150  gm.  bouillon      0.75 

50  gm.  meat  solution  or   1  egg   8.50 

2  cakes     1.10 

Total    47.90 

Calories     200 


Carbo- 

hydrates 

9.00 

12.0 

0.50 

7.3 

9.00 

12.0 

0.25 

3.7 

0.45 

0.9 

3.00 

3.5 

9.00 

12.0 

0.50 

7.3 

0.45 

0.9 

3.00 

3.5 

0.50 

7.3 

5.65 

70.4 

330 

330 

446 


DIET  IN  DISEASE 


Diet  II — To  be'  followed  at  least  seven  days. 

Protein.  Fat.  .^F**"" 
hydrates. 

Morning :         250  gm.  milk     8.5  9.00  12.0 

3  cakes     1.8  0.75  11.1 

10  o'clock:      200  gm.  bouillon     3.2  4.40  3.2 

1  egg    6.0  5.00 

Noon :                    1  boiled   pigeon    22.0  1.00  0.7 

about  200  gm.  rice  in  bouillon   5.0  2.00  40.0 

4  o'clock :      250  gm.  milk     8.5  9.00  12.0 

2  cakes     1.1  0.50  7.3 

8  o'clock:       150  gm.  bouillon    6.4  6.70  9.0 

100  gm.  sweetbreads    28.0  0.40 

Total    90.5  38.75  95.3 

Calories     370  350  390 

Entire  number  of  calories   1100 

Diet  III— To  be  followed  at  least  five  days. 

Protein.  Fat.  ^J-b^'^^ 

Morning:  2  cups    of    tea    or    coffee    with    100    gm. 

of  milk   3.4  3.60  4.8 

20  gm.  sugar     0.5  18.2 

3  cakes 1.8  0.75  11.1 

10  o'clock :       200  gm.  bouillon     3.2  4.40  3.2 

1  egg    6.0  5.00 

Noon:                200  gm.  soup     3.2  6.00  17.0 

150  gm.  beefsteak     31.0  2.20 

100  gm.  mashed  potatoes  3.1  0.85  21.3 

4  o'clock:           2  cups  tea  with  100  gm.  milk   3.4  3.60  4.8 

20  gm.  sugar     0.5  18.2 

3  cakes     1.8  0.75  11.1 

Evening:           100  gm.  scraped  ham 25.0  8.10 

200  gm.  soup     3.2  6.00  17.0 

Total     86.1  41.25  126.7 

Calories     350  380  520 

Entire  number  of  calories    1250 

Diet  IT — To  be  followed  at  least  one  week 

Protein.     Pat.    .^^-^.o-^^ 

Morning:              2  cups  tea  or  coffee,  100  gm.  milk 3.4  3.6  4.8 

20  gm.    sugar   0.5  .  .  .  18.2 

milk-toast  (50  gm. )    4.5  0.5  29.0 

10  o'cloc^ :       200  gm.  bouillon   3.2  4.4  3.2 

1  egg    6.0  5.0 

Noon :                200  gm.  soup   3.2  6.0  17.0 

150  gm.  roast  fowl   27.6  14.0  1.7 

100  gm.  carrots  or  spinach  1.0  0.2  8.1 

200  gm.  light  tlour   food    9.0  8.4  45.0 

4  o'clock:           2  cups  of  tea  with  100  gm.  milk 3.4  3.6  4.8 

20  gm.  sugar    0.5  ...  18.2 

milk-toast     4.5  0.5  29.0 

Evening:           100 gm.  cold  roast  meat   38.2  2.8 

150  gm.  tapioca  7.0  5.0  8.0 

10  o'clock  at  night:  250  gm.  milk 8.5  9.0  12.0 

Total    120.5  63.0  199.0 

Calories     495  585  815 

Entire  number  of  calories  1900 


DIET  IN  DISEASES  OF  THE  STOMACH  447 

The  following  list,  taken  from  Boas'  Magenkrankheiten,  gives  his 
diet  in  ulcer  of  the  stomach : 

First  iceek. 

Calories. 

8  A.  M. :  201)  gm.  milk  aud  Hour  soups   121.5 

10  A.  M. :  200  gm.  bouillon  with  1  egg   86.0 

12  o'clock :     200  gm.  rice  milk  soup   235.4 

farina  milk  soup  (227.4),  soup  of  30  gm.  tapioca,  1  Qgg, 

10  gm.  butter    ( 282 )    509.4 

4  p.  M.:         200  gm.  milk  (134),  50  gm.  Nestle's  food   (149.5)    284.5 

7  P.  M. :  Soup  of  30  gm.  tapioca  and  10  gm.  albumose 164.0 

During  the  day:     1  liter  milk  (at  2,  6,  9  o'clock,  330  gm.) 607.5 

Total     1498.9 

Second  week. 

The  same  diet  with  the  addition  of  100  gm.  zwieback. 

Total     1856.7 

Third  week. 

8  A.  M. :         200  gm.    milk    135.0 

50  gm.  zwieback 178.9 

10  A.  M. :  50  gm.  scraped  meat   (59.5),  1  egg   (80)    139.5 

50  zwieback   ( 178.9) ,  30  gm.  butter   (213.9)    393.8 

with  200  gm.  milk     135.0 

12  o'clock:      Soup  of  30  gm.  tapioca,  1  egg,  10  gm.  butter 282.0 

100  gm.  calves'  brain,  sweetbread,  veal  chop,  chicken,  wild 

pigeon     140.0 

3  P.  M. :  200  gm.  milk  and  tea  with  30  gm.  sugar  135.0 

50  gm.  zwieback     178.9 

7  P.  M. :  60  gm.  lean    ham    262.2 

50  gm.  zwieback     178.9 

300  gm.  milk    202.5 

Total     2361.0 

Einhorn's  diet  in  gastric  ulcer: 

First  three  days. 

Calories. 

7  A.  M.:        Milk,  150  c.c.    (5  ounces)    101 

8  A.  M.r        Milk,  150  c.c.    (5  oimces)    101 

9  A.M.:         Milk,   150  c.c.    (5  ounces) 101 

10  A.  M. :        Milk  and  strained  barley-water   (aa),  150  c.c 80 

11  A.  M.:         Milk.   1.50  c.c.    . 101 

12  noon :         Milk.  150  c.c 101 

1  P.  ii. :        Bouillon,  either  alone  or  w^ith  the  addition  of  1  to  2  teaspoon- 

fiil«  of  a  peptone  preparation,  150  c.c 30 

2  P.  M. :         Milk     101 

3  P.  M. :         Milk     101 

4  P.  M. :         Milk     101 

5  P.  M. :        ]\Iilk,  with  strained  barley  or  oatmeal 80 

6,  7,  8,  9  P.  M. :    Milk,  150  c.c .' 404 

1402 

Fourth  to  fJie  tenth  day. 

7  A.  M. :        :Milk,  300  c.c.    ( 10  ounces)    202 

9  A.  M. :         Milk,  300  c.c 202 

11  A.  M. :        Milk,  with  barley,  rice,  or  oatmeal-water,  300  c.c 160 

]   P.  M. :         One  cup  of  bouilion,  200  c.c,  and  1  egg  beaten  up  in  it 80 

3  p.  M. :         Milk.  300  c.c 202 

5  p.  M. :         Milk,  300  c.c 202 

7  P.  M. :        Milk,  with  barley-water,  300  c.c 160 


448  DIET  IN  DISEASE 

9  P.  M. :        Milk,  300  c.c 202 

1410 
Eleventh  to  the  fourteenth  day. 

7  A.  M. :         Milk,  3U0  c.c 202 

9  A.  M. :         Milk,  300  c.c 202 

And  two  crackers  softened   ( 1  ounce)    100 

11  A.  M. :        Milk,  with  barley-water,  300  c.c 160 

1  p.  M. :        One  cup  of  bouillon,  200  c.c,  1  egg  and  2  crackers 180 

3  P.  M. :        Milk,  300  c.c,  and  1  egg 282 

5  P.  M. :         Milk,   300  c.c 202 

And  2  crackers   100 

7  P.  M. :        Milk,  with  barley-water  160 

9  P.  M. :        Milk,  300  c.c 202 

1790 

Fourteenth  to  the  seventeenth  day. 

7  A.M.:        Milk,  300  c.c 202 

9  A.  M. :         Milk,  300  c.c 202 

And   2   crackers    100 

11  A.  M. :        Milk  with  barley,  300  c.c 342 

1  P.  M. :        Scraped  meat,  50  gm 60 

2  crackers,  1  cup  of  bouillon,  200  c.c 100 

3  P.  M. :         ]\Iilk,  300  cc 202 

5  P.  M. :        Milk,  300  cc 202 

1  egg   (  soft  boiled )    80 

2  crackers    100 

7  P.  M. :        Milk,  with  farina,  300  c.c 342 

9  p.  M. :        Milk,  300  c.c 202 

2134 
Seventeenth  to  the  t a enty- fourth  day. 

7  a.m.:        2  eggs   ( soft  boiled )    160 

Butter,  10  gm 81 

Toasted  bread.  50  gm 130 

Milk,  300  cc 202 

10  A.  M. :        Milk,  300  cc 202 

Crackers,  50  gm 166 

Butter,  20  gm 162 

1  p.  M. :        Lamb  chops    ( broiled ) ,  50  cc 60 

Mashed  potatoes,  50  gm 44 

Toasted  bread,  .50  gm 130 

Butter,  10  gm. :  1  cup  of  bouillon,  200  cc 81 

4  P.  M. :         The  same  as  10  A.  M 530 

6.30  P.  M. :   Milk  with  farina,  300  c.c 342 

Crackers,  50  gm 166 

Butter.  20  gm 162 

9  P.  M. :         Milk,  300  cc 202 

2820 

Lenhartz  ^  cautions  against  the  strict  abstinence  diet  in  the  treat- 
ment of  ulcer  of  the  stomach,  even  in  those  instances  in  which  there 
is  hemorrhage.  He  bases  his  conclusions  on  the  fact  that  since  ulcer 
of  the  stomach  is  most  frequently  accompanied  by  superacidity  and 
also  by  an  enfeebled  condition,  it  is  best  to  give  protein  food  early 
to  overcome  the  acidity  as  well  as  to  build  up  the  system.  The  ac- 
companying table  illustrates  his  method  of  feeding: 

1  Deutsch.  Med.  Wochenschr.,  1904,  No.  11. 


DIET  IN  Din  EASE  a  OF  THE  STOMACH 


449 


Day      after      last 

hematemesis     .  .      1       2       3       4       5 

Eggs    2       3       4       5       a 

Sugar,   gm 20     20     30 

Milk,    c.c 200  300  400  500  600 

Raw  scraped  beef, 

gui 

Milk   cooked   with 

rice,    c.c 

Zwieback,    gm.    .  . 
Ham    (raw),    gm.. 

Butter,  gm 

Calories    280  420  637  779  955 


6          7 

8 

9 

10 

11 

12 

13 

14 

7          8 

8 

8 

8 

S 

8 

s 

8 

30        40 

40 

50 

50 

50 

50 

50 

50 

700     800 

900 

1000 

1000 

1000 

1000 

1000 

1000 

35    2X35 

2X35 

2X35 

2X35 

2X35 

2X35 

2X35 

2X35 

100 

100 

200 

200 

300 

300 

300 

300 

20 

40 

40 

60 

60 

80 

100 

50 

50 

50 

50 

50 

20 

40 

40 

40 

40 

135   15SS 

1721 

2138 

2478 

2941 

2941 

3007 

3073 

The  Lenhartz  diet  as  modified  by  Lambert  to  suit  the  American 
dietary  is  as  follows : 


Day. 

Ei?gs. 

Milk. 

Sugar. 

Scraped  beef. 

I. 

2    drams     each 
dose;   total,  2 
eggs. 

4     drams    each 
dose;   total,  6 
oz. 

II. 

3      drams     per 
dose ;    tota  ,  3 
eggs. 

6    drams     per 
dose ;      total, 
10  oz. 

III. 

^   oz.  per  dose; 

1    oz.  per  dose; 

20  grams  added 

total,   4  eggs. 

total,  13  oz. 

to  eggs. 

IV. 

5     drams      per 

1^  oz.  per  dose ; 

20  grams  added 

dose;  total,  5 

total,  1  pt. 

to  eggs. 

eggs. 

V. 

6      drams     per 
dose ;  total,   6 
eggs. 

14    drams     per 
dose ;  total,  19 
oz. 

30  grams. 

VI. 

7      drams     per 

2  oz.  per  dose ; 

40  grams. 

36  grams  in   3 

dose;  total,  7 

total,  22  oz. 

doses. 

eggs. 

VII. 

4     drams      per 

2  oz.  per  dose; 

40  grams. 

70   grams,   with 

dose;  total,  4 

total,  25  oz. 

boiled    rice; 

eggs ;    also    1 

100  grams  in 

soft  -boiled 

3  doses. 

egg    every    4 

houi-s ;     total, 

4  eggs. 

VIII. 

4     drams     per 

li  OZ.  per  dose  ; 

40  grams. 

70   grams,   with 

dose ;    total,  4 

total,  28  oz. 

boiled   rice; 

eggs ;    also    1 

100  grams  in 

soft  -boiled 

8,  doses. 

egg    every    4 

hours ;     total, 

4  eggs. 

IX. 

3  oz.  per  dose; 
total,  1  qt. 

Beef  same;  rice, 
200    grams; 
zwieback,    40 
grams,    ia     2 
portions. 

X. 

4     drams    per 

Add    cooked 

40  gi-ams. 

Beef  same;  rice, 

dose;  total,  4 

oho  p  p  e  d 

200    grams; 

eggs ;    also    1 

chicken,      50 

zwieback,    40 

soft  -boiled 

grams ;      also 

grams,     in    2 

egg    every    4 

butter,    20 

portions. 

hours;     total. 

grams. 

4  eggs. 

XI.-XII. — Interval  of  feeding  made  two  hours;  milk  given  in  G-oz.  doses  with 
i  oz.  raw  egg;   butter  increased  to  40  grams,  and  various  additions  made  as  de- 
tailed above. 
29 


450  DIET  IX  DI8EASE 

In  the  Lenhartz  cure,  absolute  rest  in  bed  for  at  least  four  weeks 
is  maintained.  An  ice-bag  is  placed  on  the  abdomen,  and  left  on 
more  or  less  continually  for  two  weeks.  On  the  first  day,  even  though 
there  be  hematemesis,  200  c.c.  of  iced  milk  are  given  in  teaspoonful 
doses  together  with  two  raw,  ice-cold,  beaten  up  eggs.  Bismuth  is 
given  at  the  same  time  two  or  three  times  daily  in  single  doses  of  2 
grams,  and  continued  for  ten  days.  The  eggs  are  beaten  up  with 
sugar,  and  they  are  kept  cold  by  placing  the  cup  containing  them  in 
a  dish  filled  with  ice.  The  milk  is  increased  every  day  by  100  grams, 
and  one  additional  egg  added ;  on  the  ninth  day  the  patient  is  given 
1  liter  of  milk,  and  the  quantity  is  not  increased ;  on  the  sixth  day 
raw  scraped  beef  is  added,  and  the  quantity  is  doubled  on  the  follow- 
ing day;  on  the  seventh  and  eighth  days  the  patient  is  given  some 
well-cooked  rice  and  zwieback  (softened),  and  on  the  tenth,  raw  ham 
and  butter. 

MODIFIED  LENHARTZ  ULCER  DIET  OF  SEALE  HARRIS 

First  Day — 1  egg,  l^^  oz.  cream,  4  oz.  milk.  Mix  and  give  i^  oz.  every  hour 
from  7  A.  M.  to  7  P.  M.    Total  calories  approximate  .300. 

Second  Day — 2  eggs,  3  oz.  cream,  8  oz.  milk.  Mix  and  give  1  oz.  every  hour 
from  7  A.  M.  to  7  P.  m.     Total  calories  approximate  600. 

Third  Day — 3  eggs,  4^4  oz.  cream,  12  oz.  milk.  Mix  and  give  l^y  oz.  every  hour 
from  7  A.  M.  to  7  p.  m.     Total  calories  approximate  900. 

Fourth  Day — 4  eggs,  6  oz.  cream,  16  oz.  milk.  Mix  and  give  2  oz.  every  hour 
from  7  A.  ir.  to  7  p.  m.     Total  calories  approximate  1,200. 

FifUh  Day — 5  eggs,  lY-2  oz.  cream,  20  oz.  milk.  Mix  and  give  2^^  oz.  every  hour 
from  7  A.  M.  to  7  p.  m.     Total  calories  approximate  1,.500. 

Sixth  Day — 6  eggs,  9  oz.  cream,  24  oz.  milk.  Mix  and  give  3  oz.  every  hour 
from  7  A.  M.,  to  7  p.  m.     Total  calories  approximate  1,800. 

Seventh  to  Tenth  Day — 6  eggs,  6  oz.  cream,  20  oz.  milk.  Mix  and  give  3  oz.  at 
8,  9,  10,  11,  12  A.  M.  and  2,  .3,  4,  5,  6  p.  m.,  and  at  7  a.  m.  and  7  p.  m.  give  two 
tablespoonsful  strained  oatmeal,  2  oz.  cream,  level  teaspoonful  sugar  and  1  soft 
lioiled  egg;  at  1  p.m.  1  rounded  tablespoonful  scraped  beef,  lightly  broiled,  1 
heaping  tablespoonful  of  rice  and  3  oz.  milk.     Total  calories  approximate  2,100. 

Eleventh  to  Fourteenth  Day — Breakfast  at  7  a.  m.,  and  supper,  7  P.  m.,  2  soft 
boiled  eggs,  1  slice  of  toast,  1  pat  butter,  3  tablespoonsful  strained  oatmeal  or 
cream  of  wheat,  3  oz.  cream,  teaspoonful  sugar.  Dinner,  at  1  p.  m.,  2  tablespoons- 
ful scraped  beef  or  minced  breast  of  chicken,  2  slices  dry  toast,  2  heaping  table- 
spoonsful of  rice,  butter  and  2  tablespoonsful  ice  cream,  I  egg,  1  oz.  cream  and  3 
oz.  milk  at  9  and  11a.  Ji.  and  3  and  5  P.  m.     Total  calories  2,800. 

Fifteenth  to  Twenty-first  Day — Same  as  from  eleventh  to  fourteenth  days  ex- 
cept that  the  amount  of  cereal,  cream  and  chicken  or  beef  may  be  increased, 
baked  Irish  potato  may  be  substituted  for  rice,  and  gelatin  or  boiled  custard 
for  ice  cream.  One  egg,  1  oz.  cream  and  4  oz.  milk  should  be  given  at  10  a.  m. 
and  4  p.  m.     Total  calories  approximate  3,000. 

From  the  Third  to  Sixth  Week — The  diet  should  be  the  same  as  in  the  third 
week  except  tliat  strained  orange  juice  may  be  given  for  breakfast  and  purees  of 
peas,  beans  and  potatoes  may  be  given  for  dinner.  Soft  green  vegtables  mashed 
through  cloth  or  seive  may  be  added.     Total  calories  approximate  3, .500. 

Xote. — The  egg,  milk  and  cream  mi.xture  should  be  kept  in  a  covered  dish  with 
ice  packed  around  it.  The  amount  for  each  feeding  should  be  given  slowly  and 
with  a  spoon,  and  with  the  same  exactness  and  regularity  as  if  it  were  medicine. 

The  scraped  beef  should  be  made  into  a  patty  and  lightly  broiled  with  a  little 
butter  and  salt. 

The  rice  and  oatmeal  should  be  cooked  for  several  hours. 

The  dry  toast  should   be  in   slices  about  4  x  4  x  i^   inciies   in   size.     The  crust 


MODIFIED  LEyHANTZ  VLCER  DIET  OF  ISEALE  HARUIS 


451 


should  be  removed  and  the  patient  instnu-ted  to  chew  it  until  it  becomes  liquid 
with  the  saliva. 

LEXHARTZ'S  DIET,  AS  MODIFIED  BY  US   FOR   A:\IERICAN   PATIENTS 


8  A.  M. 
10  A.  M. 
12  M.: 

4   P  M. 

8  A.  M 
10    A.  M 

12   M.: 
2  P.  M. 

4    P    M . 

6   A.  M. 

8  A.  M. 
10   A.  M. 

12   M.: 
2   P.  M. ; 


0    A.  M. 

8   A.  M. 
10   A.  M. 

12  M.: 
2  p.  M. : 


6  A.  M. ; 


8    A.  M. 
10   A.  M. 


12   M.: 

2    P.  M. 


6    A.  M. 


8    A.  M. 
10    A.M. 


12  M.: 

2    P.  M. 


6  A.  M. ; 


8 

A. 

M. 

10 

A. 

M. 

12 

M 

2 

P. 

M. 

Iced  milk,  3  oz. 

Iced  egg,  1. 
Milk,  2  oz. 
Egg,  1. 

Milk,  3  oz. 
Egg,  1. 
Milk.  4  oz. 
Egg,  1. 
Milk.  3  oz. 

Milk,  3d  r. 

Milk  sugar,   1  dr. 

Egg,  1. 

Milk,  3  oz. 

Milk  sugar,  1  dr. 

Egg,  1. 

Milk,  4  oz 

Milk  sugar,  2  dr. 

Milk,  4  oz. 
Milk  sugar,  2  dr. 
Egg,   1. 
:\Iilk,  4  oz. 
^lilk  sugar,  2  dr. 
Egg,  1. 
Milk,  5  oz. 
Milk  sugar,  2  dr. 

Milk,  5  oz. 
Milk  sugar,  2  dr. 
Eggs,  2. 
Milk,  5  oz. 
Milk  sugar,  2  dr. 
Eggs,  2. 
Milk,  5  oz. 
Milk  sugar,  2  dr. 

Milk,  5  oz. 
Milk  sugar,  3  dr. 
Eg'gs,  2. 
Milk,  6  oz. 
Milk  sugar,  2  dr. 
Eggs,  2. 
Milk,  6  oz. 
Milk  sugar,  3  dr. 
Raw  beef,   1  oz. 

Milk,  6  oz. 
Milk  sugar,  3  dr. 
Eggs,  2  raw. 
Milk,  7  oz. 
Milk  sugar.  3  dr. 
Milk  rice,  3  oz. 
Eggs,  2    (soft  boiled 
Milk,  6  oz. 
Milk  sugar,  4  dr. 
Raw  beef,  2  oz. 


First  Day 

0   P.  M. 

Total: 


Second  Day 

6   P.  M. 

Total : 


Third  Day 

4  P.  M. 
6  p.  M. 

8   P.  M. 
Total: 


Fourth  Day 

4  p.  M. 
6  p.  M. 

8    P.  M. 

Total: 


Fifth  Day 

4  P.  M. 
6   p.  M. 

8   p.  M. 

Total : 


Sixth  Day 

4  P.  M. 
6    P.M. 

8    P.  M. 

Total : 


Seventh  Day 

4   p.  M. 
6  p.  M. 

8    P.  M. 

Total: 


Milk,  2  oz. 

Milk,  7  oz. 
Calories,  280. 

Egg,  1. 
Eggs,  3. 
Milk,   10  oz. 
Calories,  420. 


Egg,   1. 
Milk,  3  oz. 
Milk  sugar,  1  dr. 
Egg,  1. 
Eggs,   4. 
Milk,  10  oz. 
Milk  sugar,  5  dr. 
Calories,  637. 

Egg,    1. 
Milk,  4  oz. 
Milk  sugar,  2  dr. 
Egg,   1. 
Eggs,  5. 
Milk,   17  oz. 
Milk  sugar.  1  oz. 
Calories,  777. 

Egg,  1. 
Milk,  5  oz. 
Milk  sugar,  2  dr. 
Egg,  1. 
Eggs,  6. 
^lilk,   10  oz. 
Milk  sugar.  1  oz. 
Calories,  955. 

Eggs,  2. 

Milk,  6  oz. 

Milk  sugar,  2  dr. 

Egg,  1. 

Eggs,  7. 

Raw  beef,  1  oz. 

Milk,  23  oz. 

Milk  sugar,  10  dr. 

Calories,  1135. 

Eggs,  2    (raw). 
Milk,   7  oz. 
Milk  sugar,  3  dr. 
Eggs,  2    (soft  boiled). 
Eggs,  8. 
Milk,  27  oz. 
Milk  sugar,   13  dr. 
Milk  rice,  3  oz. 
Raw  beef,  2  oz. 
Calories,  1585. 


452 


DIET  IS  DISEASE 


6   A.  M. 


8   A.  M. 
10  A.  M. 


12  M.: 
2   P.M. 


6  A.  M. : 

8  A.  M. ; 
10  A.M.; 


12  M.: 

2  P.  M. ; 


4    P.  M. 
6   A.  M. 

8    A.  M. 
10   A.M. 

12  M.: 
2  P.  M. 

4   P.  M. 
6   A.  M. 


8   A.  M. 
10    A.  M. 


12  M.: 
2  P.  M. 


6   A.  M. 


Milk,  7  oz. 
Milk  sugar,  3  dr. 
Eggs,  2   ( raw ) . 
Milk,  7  oz. 
Milk  sugar,  3  dr. 
Milk  rice,  3  oz. 
Eggs,  2    (soft  boiled 
Milk,  8  oz. 
Milk  sugar,  3  dr. 
Raw  beef,  2  oz. 
ZAvieback,  5  dr. 

Milk,  6  oz. 

Milk  sugar,  3  dr. 

Eggs,  2. 

Milk,  6  oz. 

Milk  sugar,  3  dr. 

Milk  rice,  4  oz. 

Eco's,  2. 

Milk,   7  oz. 

Milk  sugar,  3  dr. 

Raw  beef,  2  oz. 

Zwieback,  10  dr. 

Eggs,   2. 

Milk,  6  oz. 
Milk  sugar,  3  dr. 
Raw  beef,  2  oz. 
Esigs,  2. 
Butter   i   dr. 
Milk,  6  oz. 
Milk  sugar,  3  dr. 
Milk  rice,  4  oz. 
Butter,  1  dr. 
Eggs,  2. 
Butter,  ^  dr. 
Milk,  7  oz. 
Milk  sugar,  3  dr. 
Raw  beef,  2  oz. 
Zwieback,  12  dr. 
Butter,  1  dr. 


Eifjhth  Day 

4   P.  M. 
6  P.  M. 

8    P.  M. 

Total: 


Eggs,   2. 

;     Milk,  6  oz. 

Milk  sugar,  3  dr. 

Raw  beef,  2  oz. 

Zwiel)ack,  1  oz. 

Butter,  5  dr. 
:      Eggs,  2. 
;     Milk,  6  oz. 

Milk  sugar,  3  dr. 

Milk  rice,  5  oz. 
Eggs,  2. 

Milk,  7  oz. 

Milk  sugar,  3  dr. 

Raw  beef,  2  oz. 

Zwieback,  1  oz. 

Butter,  5  dr. 

;      Milk,  6  oz. 

Milk  sugar,  3  dr. 
Raw  beef,  2  oz. 


'Ninth  Day 

(3  P.  M. 


8  p.  M. 
10   P.  M. 

Total : 


Tenth  Day 

6   P.  M. 
8    P.M. 

10  p.  ir. 
Total: 


Eleventh  Day 

4  p.  M. 
6   P.  M. 


8  P.  M. 

10    p.  M. 

Total: 


Tioelfth  Day 

I        4  p.  M. 
6   P.  M. 


Eggs,  2   (raw) . 

Milk,  8  oz. 

Milk  sugar,  4  dr. 

Eggs,  2    (soft  boiled). 

Eggs,  8. 

Milk,  30  oz. 

Milk  sugar,  13  dr. 

Milk  rice,  3  oz. 

Raw  beef,  2  oz. 

Zwieback,  5  dr. 

Calories,    1721. 

Milk,  7  oz. 
Milk  sugar,  4  dr. 
Milk  rice,  3  oz. 
Eggs,  2. 
Milk,  7  oz. 
Eggs,  8. 
Milk,  33  oz. 
Milk  sugar,   13  dr. 
Milk  rice,  7  oz. 
Raw  beef,  2  oz. 
Zwieback,  10  dr. 
Calories,  2138. 

Butter,  I  dr. 
Milk,  7  oz. 
Milk  sugar,  4  dr. 
Milk  rice,  3  oz. 
Butter,  1  dr. 
Eo-fs    2 
Butter,  A  dr. 
Milk,  7  oz. 
Eggs,  8. 
Milk,  33  oz. 
IMilk  sugar,  13  dr. 
Milk  rice,  7  oz. 
Raw  beef,  4  oz. 
Zwieback,  12  dr. 
Butter,  5  dr. 
Calories,  2478. 


Eggs,  2. 
Milk,  7  oz. 
Milk  rice,  5  oz. 
Milk  sugar,  4  dr. 
Eggs,  2. 
Milk,  8  oz. 
Eggs,   8. 
Milk,  34  oz. 
Milk  sugar,  13  dr. 
Milk  rice,  10  oz. 
Zwieback,  2  oz. 
Raw  beef,  4  oz. 
Butter,   10  dr. 
Calories,  2491. 


M^ifk,'  7  oz. 
]\Iilk  sugar,  4  dr. 


MODIFIED  LESHARTZ  ULCEK  DIET  OF  s'EAf.E  HARRIS 


453 


Zwiehat-k,    1   oz. 

'SlUk  rice,  5  oz. 

Butter,  5  dr. 

8  p.  Jr.: 

Eggs,  2. 

8 

A 

M.: 

Eggs,  2. 

10  p.  M.: 

Milk,  8  oz. 

10 

A. 

M.: 

Milk,  I)  oz. 
Milk  rice,  5  oz. 
^lilk  sugar,  3  dr. 

Total : 

Eggs,  8. 
Milk,  34  o». 
Milk  sugar,  13  dr. 

12 

11 

Eggs,  2. 

Milk  rice,  10  oz. 

2 

P. 

M.: 

Milk,  7  oz. 
Milk  sugar,  '.i  dr. 
Raw  beef.  2  oz. 
Zwieback,  1  oz. 
Butter,  .')  dr. 

Zwieback,  2  oz. 
Butter,  10  dr. 
Raw  beef.  4  oz. 
Calories,  2491. 

Thirteenth  Day 

6 

A. 

51.: 

Milk,  6  oz. 

4   p.  M. : 

Eggs,  2. 

Milk  sugar,  3  dr. 

6  p.  M. : 

Milk,  7  oz. 

Raw  beef,  2  oz. 

^Milk  sugar,  4  dr. 

Zwieback,  Ih  oz. 

]Milk  rice,  5  oz. 

Butter,  G  dr. 

8  P.  M.: 

Eggs,  2. 

8 

A. 

M. : 

Eggs,  2. 

10  P.M.: 

Milk,  8  oz. 

10 

A. 

M. : 

Milk,  6  oz. 

]Milk  sugar,  3  dr. 

Milk  rice,  5  oz. 

Total : 

Eggs,  8. 

Milk  rice,  10  oz. 

Milk,  34  oz. 

12 

yi 

Eggs,  2. 

Zwieback,  3  oz. 

2 

P. 

M. : 

Milk,  7   oz. 
Milk  sugar,  3  dr. 
Raw  beef,  2  oz. 
Zwieback,   li  oz. 
Butter,  6  dr' 

Fourtee 

ith  Day 

Milk  sugar,  13  dr. 
Raw  beef,  4  oz. 
Butter,  12  dr. 
Calories,  3007. 

6 

A. 

M.: 

Milk,  6  oz. 

4  p.  M. : 

Eggs,  2. 

Milk  sugar,  3  dr. 

6  P.  M. : 

Milk,  7  oz. 

Raw  beef,  2  oz. 

Milk  sugar,  4  dr. 

Zwieback,  2  oz. 

Milk  rice,  5  oz. 

Butter,  6  dr. 

8  P.  M. : 

Eggs,  2. 

8 

A. 

M. : 

Eggs,  2. 

10  P.  M.: 

:\Iilk,  8  oz. 

10 

A. 

AI.: 

Milk,  6  oz. 
Milk  sugar,  3  dr. 
Milk  rice,  .5  oz. 

Total  : 

Zwieback,  4  oz. 
Butter,  12  dr. 
:\Iilk  rice,  10  oz. 

12 

M 

Eggs,  2. 

Eggs,.  8. 

2 

P. 

M.: 

Milk,   7  oz. 
Milk  sugar,  3  dr. 
Raw  beef,  2  oz. 
Zwieback,  2  oz. 
Butter,  6  dr. 

Milk,  34  oz. 
Milk  sugar,  13  dr. 
Raw  beef,  4  oz. 
Calories,  3073. 

We  prefer  the  Lenhartz  treatment  rather  than  the  Leube  cure,  for 
a  restriction  to  a  liquid  diet  is  often  unnecessary,  quite  distressing  to 
the  patient,  and  leads  to  great  loss  of  flesh,  weakness,  and  anemia. 
This  treatment  is  especially  useful  in  cases  accompanied  by  hemor- 
rhage. Quite  satisfactory  results  are,  however,  often  obtained  by  the 
Leube  treatment,  and  at  times,  on  account  of  the  severe  nausea, 
vomiting,  and  pain,  one  is  forced  to  follow  this  form  of  treatment. 

According  to  our  observation  of  521  cases  of  ulcer  treated  by  the 
rest  cure,  of  which  404  underwent  the  Leube  treatment  and  117  the 
Lenhartz  treatment,  72  per  cent,  recovered  by  the  Leube  cure  and 
66  per  cent,  by  the  Lenhartz.  This  is  in  comparison  from  40  to  50 
per  cent,  of  cures  of  cases  treated  as  ambulatory  cases,  and  71  per 
cent,  treated  surgically.     It  is  evident  that  when  an  ulcer  patient  is 


454  DIET  I\  DI8EASE 

treated  medically  he  should  be  thoroughly  treated,  and  ambulatory 
treatment  should,  if  possible,  not  be  instituted.  We  also  maintain 
the  belief  that  many  ulcer  cases  do  not  recover  because  the  treatment 
is  not  sufficiently  prolonged,  and  in  some  cases  the  rest  cure  should  be 
extended  to  six  or  even  eight  weeks. 

Kecently  Sippy  has  evolved  a  method  of  treating  peptic  ulcer 
which  according  to  our  observations  in  a  large  number  of  cases  has 
yielded  the  most  gratifying  results. 

Inasmuch  as  it  is  generally  admitted  that  a  peptic  ulcer  heals  if  its 
surface  is  not  continuously  exposed  to  the  digestive  action  of  the  gastric 
juice,  Sippy 's  treatment  consists  in  protecting  the  ulcer  from  the  acid 
corrosion,  until  it  is  healed  by  shielding  it  from  the  corrosive  effect 
of  the  gastric  secretion.  He  accomplishes  this  by  maintaining  a 
neutralization  of  the  free  hydrochloric  acid  from  early  in  the  morning 
until  late  at  night,  usually  from  seven  a.  m.  until  ten  thirty  p.  m,,  or 
during  the  entire  period  when  food  or  gastric  secretion  is  in  the 
stomach. 

If  an  excessive  secretion  is  present  at  night  this  is  removed  by 
aspiration,  until  the  secretion  has  disappeared. 

The  neutralization  is  effected  by  frequent  feedings  and  the  ad- 
ministration of  alkalis,  given  freely  and  at  frequent  intervals. 
Nourishment  is  given  from  the  very  on.set  of  the  treatment,  the 
preliminary  starvation  and  administration  of  nutrient  enemata  com- 
mon to  other  forms  of  medical  treatment,  are  of  little  value,  according 
to  Sippy.  The  patient  remains  in  bed  for  three  to  four  weeks.  Three 
ounces  of  a  mixture  of  equal  parts  of  milk  and  cream  are  given  every 
hour  from  7  a.  m.  to  7  r.  m.  After  two  or  three  days  soft  eggs  and 
well  cooked  cereals  are  gradually  added  until  in  ten  days  the  patient 
receives  3  ounces  of  milk  and  cream  mixture  every  hour,  three  or  four 
boiled  eggs  and  9  to  12  ounces  of  a  cereal  each  day.  Cream  soups  of 
various  kinds,  vegetable  purees,  and  other  soft  foods  may  be  sub- 
stituted now  and  then  as  desired.  One  egg  is  given  at  a  time,  and 
three  ounces  of  a  cereal  at  a  single  feeding,  the  cereal  being  measured 
after  it  is  prepared.  The  cereal  and  eggs  are  given  alternately,  and 
taken  at  the  same  time  as  the  three  ounce  mixture  of  milk  and  cream. 

The  total  bulk  of  each  feeding  should  not  be  over  six  ounces.  After 
a  longer  or  shorter  period  according  to  the  condition  of  the  patient, 
a  large  variety  of  soft  and  palatable  foods  may  be  used  such  as: 
jellies,  marmalades,  custards,  creams,  etc.  The  basis  of  the  diet,  how- 
ever, should  be  milk  and  cream,  eggs,  cereals,  vegetable  purees  and 
bread  and  butter.  Alkalis  are  administered  from  the  very  beginning 
of  the  treatment,  between  the  feedings,  to  neutralize  the  acid  secre- 
tion; powders  consisting  of  heavy  calcined  magnesia,  10  grains  with 
sodium  bicarbonate  10  grains,  being  alternated  with  powders  of  bis- 
muth subcarbonate  10  grains,  and  sodium  bicarbonate  30  grains.  It 
is  also  advisable  to  give  the  powders  every  half  hour  after  the  last 


MODIFIED  I.EXHARTZ   ULCER  DIET  OF  SEALE  HARIilii  455 

night  feeding  for  a  number  of  doses.  According  to  Sippy,  if  an 
adequate  quantity  of  alkali  is  utilized  on  aspirating  tlie  stomacii,  no 
free  hydrochloric  acid  will  be  found  at  any  time  during  the  period  in 
which  it  contains  food.  If  the  acidity  is  not  promptly  controlled  by 
giving  the  usual  amount  of  alkali,  the  dose  is  gradually  increased  by 
adding  10  grains  of  sodium  bicarbonate  to  each  powder,  until  the 
acidity  is  controlled. 

The  after  mauatiement  of  these  patients  is  important ;  the  hourly 
feedings  and  alkaline  powders  must  be  continued  even  after  the 
patient  is  pursuing  his  regular  occupation.  If  this  be  impossible,  he 
may  be  allowed  a  light  breakfast  of  from  ten  to  twelve  ounces  con- 
sisting of  cereal,  eggs,  bread  and  butter,  or  any  soft  food.  A  thermos 
bottle  containing  equal  parts  of  cream  and  milk  can  be  utilized  for 
conveniently  supplying  the  hourly  feedings.  Three  to  four  ounces 
can  be  taken  hourly  until  noon,  when  a  light  luncheon  may  be  taken, 
consisting  of  easily  digestible  meats.  During  the  afternoon,  three  to 
four  ounces  of  milk  and  cream  should  be  taken  hourly  until  the  eve- 
ning meal.  The  total  bulk  of  food  should  not  be  sufficient  to  cause 
a  greater  increase  in  weight  than  is  desired.  If,  for  any  special 
reason,  the  hourly  feedings  cannot  be  maintained,  the  three  usual 
meals  should  be  substituted,  and  the  powders  taken  every  hour  for 
three  doses  after  a  light  breakfast ;  one  hour  after  luncheon  a  powder 
should  be  taken,  two  powders  at  the  end  of  the  second  and  third 
hours,  and  one  at  the  end  of  the  fourth  hour. 

At  the  end  of  from  ten  to  twelve  weeks,  the  feedings  may  be  in- 
creased to  two  hour  intervals,  and  the  powders  continued  midway 
between  the  feedings.  About  twice  the  amount  of  food  should  be 
taken,  at  each  feeding,  and  two  powders  midway  between  the  feed- 
ings. At  the  end  of  twenty  or  more  weeks,  the  patient  may  partake 
of  three  meals  daily  and  may  be  allowed  a  glass  of  equal  parts  of  milk 
and  cream,  midway  between  breakfast  and  luncheon — and  between 
luncheon  and  dinner;  two  powders  should  be  given  between  breakfast 
and  the  milk  and  cream  and  two  powders  between  the  milk  and 
cream  and  luncheon.  Similarly,  two  powders  should  be  taken  be- 
tween the  afternoon  feedings,  and  two  powders,  one  and  two  hours 
after  the  evening  meal,  and  again  two  powders  three  hours  after  the 
evening  meal. 

Sippy  advises  that  it  is  best  to  continue  the  five  feedings  each  day 
with  powders  between  as  directed,  beginning  with  the  twentieth  week 
of  treatment,  for  a  period  of  four  to  live  months  longer.  He  main- 
tains that  no  possible  harm  can  be  accrued,  even  after  the  ulcer  has 
healed.  All  danger  that  might  arise  from  the  continued  use  of  the 
alkali,  can  be  overcome  by  interrupting  the  administration  of  the 
powders  for  a  week  at  the  end  of  each  five  to  six  weeks  period. 

Sippy  advises  the  same  character  of  treatment  for  peptic  ulcer 
causing  pyloric  obstruction  as  for  those  not  causing  obstruction.     In 


456 


DIET  ly  DISEASE 


about  one  case  in  ten  he  maintains  that  the  obstruction  is  occasioned 
by  an  anatomic  narrowing  due  to  the  tissue  infiltration  produced  by 
the  ulcer.  In  these  cases,  the  treatment  differs  from  that  of  the  non- 
obstructive type,  in  that  larger  amounts  of  the  alkaline  powders  are 
required,  and  that  aspiration  of  the  stomach  is  indicated  each  night, 
a  half  hour  after  taking  the  last  powder,  Sippy  prescribes  as  much 
as  100  grains  of  sodium  bicarbonate  every  hour  between  the  feedings, 
and  every  half  hour  after  the  last  feeding  until  10  p.  m.,  to  overcome 
the  free  acid.  Ordinarily,  ten  to  thirty  grains  added  to  each  powder 
is  sufficient  to  produce  a  favorable  result. 

It  may  be  necessary,  according  to  this  writer,  to  aspirate  again  at 
twelve  or  one  o  "clock  at  night,  and  to  repeat  the  aspiration  at  four  or 
five  A,  M. 

Usually,  after  a  third  or  fourth  night  of  this  treatment,  there  is  no 
longer  an  excessive  secretion  after  midnight. 

Sippy  orders  a  seven  hour  motor  meal  at  the  end  of  a  week  or  two, 
to  determine  whether  the  stomach  has  improved  in  its  power  to  empty 
itself.  He  finds  that  in  most  instances  of  ulcer  associated  with  pyloric 
obstruction,  the  degree  of  retention  is  greatly  reduced  after  a  week 
or  two  of  treatment,  and  that  man.y  of  these  cases  can  be  effectually 
cured  by  this  plan  of  treatment,  without  surgical  intervention, 

"While  we  have  found  the  Sippy  cure  of  the  greatest  help  in  the 
treatment  of  peptic  ulcer,  we  cannot  agree  with  the  author  of  this 
plan  of  treatment,  that  any  method  of  treatment  other  than  surgical 
intervention  can  be  of  any  permanent  help  in  cases  of  pyloric  obstruc- 
tion produced  by  organic  disease. 

The  following  diet  list  presents  our  method  of  feeding  during  the 
Sippy  Cure,  Either  sodium  bicarbonate  with  calcined  magnesium  or 
sodium  bicarbonate  with  bismuth  subearbonate  are  given  alternately 
on  the  half  hours  from  7.30  a.  m  to  10.30  p.  m. 


Hour 
A.  M. 

7 


9 

10 
11 

12 


Days. 
1  to  5. 

Milk   and 
Cream 


Milk    and 
Cream 

Milk    and 
Cream 

Milk    and 
Cream 

Milk    and 
Cream 

Milk    and 
Cream 


Sixth. 

Soft  egg 
Milk    and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 


7  to  S. 

Milk  and 
Cream 


Milk  and 

Cream 

Soft  egg 

Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 


9  to  10. 

Cereal 
Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 


11  to  IJ, 

Soft  egg 
Cereal 
Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
Cream 

Milk  and 
'    Cream 

Milk  and 
Cream 


MODIFIED  LENHARTZ  ULCER  DIET  OF  SEALE  HARRLS  457 


Hour 

Days 
lto5 

Sixth              7  to  S 

DtolO 

11  to  L't 

p.  ii. 

Milk    and 

Milk  and        Soft  e. 

^g 

Cereal 

Egg 

Cream 

Cream           Cerea 

il 

Egg 

Cocoa 

1 

Milk 
Cr( 

and 
?am 

I         Cocoa 

Custard 

2 

Milk    and 

Milk  and          Soft 

egg 

Milk  and 

INIilk  and 

Cream 

Cream           Milk 

and 

I              Cream 

Cream 

Cream 

3 

Milk    and 

:\nik  and          Milk 

and 

[         Milk  and 

:\Ii]k  and 

Cream 

Cream               Cream 

Cream 

Cream 

4 

Milk    and 

:\rilk  and         Milk 

and 

Milk  and 

Milk  and 

Cream 

Cream               Cr( 

?am 

Cream 

Cream 

5 

!Milk    and 

]\Iilk    or          Cerea 

il 

Milk  Toast 

:\Iilk  Toast 

Cream 

cocoa              ^Milk 

and 

I          Egg  and 

Egg  and 

Soft  egg               Cream 

Cocoa 

Cocoa 

6 

Milk    and 

Milk  and          Milk 

and 

Milk  and 

Milk  and 

■  Cream 

Cream               Cream 

Cream 

Cream 

7 

Milk    and 

Milk  and          Milk 

and 

Milk  and 

Milk  and 

Cream 

Cream               Cream 

Cream 

Cream 

Milk  and  Cream  ea 

ich  : 

114  oz. 

Hour, 

Days. 

A.M. 

7 

loth. 

16th. 

17  to  IS. 

19th. 

E^g,    cereal 

Egg,  cereal 

Soft  egg 

Milk  and 

Milk  and 

Milk  and 

Cereal, 

Cream 

Cream 

Cream 

Cocoa 

8 

Milk  and 

Milk  and 

Milk  and 

Milk  and 

Cream 

Cream 

Cream 

Cream 

9 

Milk  and 

Milk  and 

Milk  and 

Chicken 

Cream 

Cream 

Cream 

broth 

10 

Milk  and 

Milk  and 

Milk  and 

Milk  and 

Cream 

Cream 

Cream 

Cream 

11 

Milk  and 

Milk  and 

Milk  and 

Milk  and 

Cream 

Cream 

Cream 

Cream 

12 

Milk  and 

Milk  and 

Milk  and 

Milk  and 

Cream 

Cream 

Cream 

Cream 

P.M. 

2  eggs. 

Egg,  milk 

Minced 

Minced 

cocoa 

Cream-milk 

chicken, 

chicken, 

1 

Milk  Toast 

Toast, 

Milk. 

Cocoa, 

Vanilla  Ice- 

Milk Toast, 

Dry  Toast, 

cream 

Vanilla   Ice- 
cream 

Vanilla  Ice- 
cream 

2 

Milk  and 

Milk  and 

Milk  and 

Milk  and 

Cream 

Cream 

Cream 

Cream 

3 

Milk  and 

Milk  and 

Milk  and 

Milk  and 

Cream 

Cream 

Cream 

Cream 

4 

Milk  and 

Milk  and 

Milk  and 

Milk  and 

Cream 

Cream 

Cream 

Cream 

5 

Milk  Toast 

Milk  Toast 

Milk  Toast 

Milk  Toast, 

Egg,  cocoa 

Egg,  cocoa 

Egg,  cocoa 

Egg,  cocoa 

6 

Milk  and 

Milk  and 

Milk  and 

Milk  and 

Cream 

Cream 

Cream 

Cream 

7 

Milk  and 

Milk  and 

Milk  and 

Milk  and 

Cream 

Cream 

Cream 

Cream 

Milk  and  Cream  each  IV2  oz. 


458 


DIET  IN  DISEASE 


Hour.  Days. 

A.  M.                                   20th.                                  21st.  22nd  on 

7  2  eggs,                                2   eggs,  Milk  and 

Cocoa                                1  slice  toast  Cream 
1  slice  dry                        Butter 

toast 
Butter 

8  Milk  and                           Milk  and  Milk  and 

Cream                                 Cream  Cream 

9  Milk  and                           Milk  and  Cereal, 

Cream                                 Cream  Milk  and 

Esr2                                   Egg  Cream 

Egg 

10  Milk  and                           Milk  and  Milk  and 

Cream                                 Cream  Cream 

11  Broth                                  Milk  and  Milk  and 

Cream  Cream 

12  Milk  and                           Milk  and  Milk  and 
p.  M.                                   Cream                                 Cream  Cream 

1  Minced                                1  Lamb  or  Chop  or 

chicken                              Mutton  minced 

1  slice  dry                            Chop  chicken, 

toast,                                  Broiled,  Dry  Toast, 

Butter,                               Dry  Toast,  Strained 

Cocoa,                                 Cocoa,  Vegetable 

Spinach                              Butter,  or   Baked 

Asparagus  Potato, 

or  Baked  Cocoa, 

Potato  Butter 

2  Milk  and                            Milk  and  Milk  and 

Cream                                 Cream  Cream 

3  Broth                                  Milk  and  Milk  and 

Cream  or  Cream 

Milk  and 

Egg 

4  Milk  and                           Milk  and  Milk  and 

Cream                                 Cream  Cream 

5  2   eggs,                               2  eggs,  Stewed 
Cereal,                                Cereal,  Fruit   or 
Milk  toast.                        Milk  Toast,  Baked 
Cocoa                                Cocoa  Apple. 

2  eo'gs. 
Cereal, 
Milk  Toast, 
Cocoa 

6  Milk  and                           Milk  and  Milk  and 

Cream                                 Cream  Cream 

7  Milk  and                           Milk  and  Milk  and 

Cream                                 Cream  Cream 
Milk  and  Cream  each  1  li.  oz. 

Modified  Sippy  Diet  followed  by  the  authors  in  mild  cases  of  peptic 
ulcer. 

MILK  AND  CREAM  aa  oz.  iss.  every  hour  from  7  a.  m.  to  7  P.  M. 
9-7.3  days. 
A.  M  P.  M.  Medicines. 

n  on  lln  n'-in j Heavy  calcined  magnesia    grs.  s. 

9  30  it^'^Hi    1  Sodium   bicarbonate    gr3.  x. 

11.30  7.30-9.30     •  •  [ 


MODIFIED  LENHARTZ  ULCER  DIET  OF  tiElLE  HARRIS  459 

Medicines. 

J  Bismuth   subcarbonate    grs.  x. 

1  Sodium  bicarbonate    grs.  xx. 

J-'i  dui/ti  following. 

Milk  and  cream   aa  oz.  iss. 


A.M. 

p.  M. 

8.30 

12.30-2.30 

10.30 

4.30-U.30 

8.30-10.30 

A.M.                               P.  M 
7  3     

11  7    

A.  il.  P.  M. 

9  1  and  5    Milk  and  egg  or  cocoa. 

A.  M.  p.  M.  Medicines. 

7.30  3.30     j'Hea\y  calcined   magnesia    grs.  x 

11.30  7.30     1  Soda    bicarbonate    grs.  x 

9.30  1.30     


5.30 
9.30 


Bismuth  subcarbonate    grs.  x. 

1  Soda  bicarbonate  grs.  xx. 


4— >  dai/s  foUou-ing. 


p.  M. 

3-7     Milk  and  cream   tia  oz.  iss. 

Oat  meal,  egg  and  cocoa. 

P.  M. 

1  and  5    Milk  toast,  egg  and  cocoa. 

P.  M.  Medici)ies. 

3.30     J'EIea\'j'  calcined  magnesia grs.  v. 

7.30     |^?odium   bicarbonate    grs.  x. 

p.  M. 

_■;'„     Bismuth  subcarbonate    srs 

0.30     ...    


Q  „„  I  Sodium   bicarbonate    grs.  xx. 

To  he  foUoiced  for  some  weeks. 

A.  M.  P.  M. 

7  3-7     Milk  and  cream aa  oz.  iss. 

11  Milk  and  egg  or  cocoa. 

9  1-5     Soft  diet  without  acids. 

A.  M.  p.  M. 

7.30  3.30     f Heavy  calcined  magnesia    -grs.  x. 

11.30  7.30     \Sodium   bicarbonate grs.  x. 

A.  M.  P.  M. 

'?y^     )  Bismuth  subcarbonate    grs.  x. 

q'„^     "j  Sodium   bicarbonate    grs.  x. 

As  required  additional  Sodium  Bicarbonate    grs.  x  to  grs.  xx. 

Based  upon  established  clinical  histo-pathological  and  physiological 
facts,  Smithies  advises  the  following  diet  in  ulcer.  Days  1  to  7 
(Time  varies  according  to  patient's  condition). 

By  Mouth.  One-half  ounce  warm  water  hourly  when  awake.  Patient  chews 
paraffin  wax  for  fifteen  minutes  at  least  once  in  two  hours.  Juice  of  sweet  orange 
or  grape  fruit  occasionally. 

By  Rectum.  Nutrient  enema  consisting  of  50  per  cent,  alcohol  1  ounce,  glu- 
cose syrup  1  ounce,  and  normal  salt  solution  6  ounces  every  four  hours.  The 
enemata  are  preceded  by  a  cleansing  irrigation  of  the  colon  with  normal  salt  solu- 
tion. They  are  given  at  body  temperature  by  the  drop  method  at  the  rate  of 
from  30  to  60  drops  per  minute.  Calories  daily  approximately  1000.  During 
the  first  two  days,  tr.  opii  il  x  is  added  to  each  second  enema. 

Days  3  to  14   (case  of  average  severity). 


460  DIET  IX  DISEASE 

By  Mouth.  From  4  to  6  ounces  of  water  gruel  at  temperature  of  100°  F.  The 
gruel  is  taken  slowly  through  a  glass  tube.  Gruels  are  made  from  rice,  cream 
of  wheat,  oatmeal,  sago,  corn-meal,  malted  milk,  macaroni  and  vermicelli,  rusks, 
potato,  asparagus,  cauliflower,  beans,  peas,  and  boiled  onion.  They  are  strained 
before  feeding.  Flavoring  with  cotl'ee,  chocolate,  vanilla,  caramel,  etc.,  renders 
the  cereal  gruels  palatable  and  their  administration  easier.  To  the  vegetable 
gruels  small  quantities  of  arrowroot  or  cornstarch  are  added  to  secure  a  thin 
emulsion.  Betore  each  feeding,  paraffin  wax  is  chewed  for  live  minutes.  Warm 
water  or  sweet  orange  or  grapefruit  juice  are  allowed  as  desired,  but  never  in 
greater  quantity  than  1  ounce  at  a  time. 

By  Rectum.  During  the  first  two  days  of  mouth  feeding,  two  alcohol  glucose- 
saline  nutrient  enemata  are  given.  During  the  second  two  days,  one  such  nutri- 
ent enema  is  administered.  After  the  fourth  day  of  mouth  feeding  no  rectal 
feedings  are  given  in  the  average  case.     Calories  approximately  800. 

Days  14  to  21. 

6.30  A.  M.  A  glass  of  hot  water  and  1  teaspoonful  of  non-eflfervescent  sodium 
phosphate. 

7.30  A.  M.  One  ounce  of  sweet  orange  or  grape-fruit  juice,  2  ounces  of  thin 
cream  of  wheat,  or  farina,  or  well-cooked  rice,  or  corn-meal,  2  ounces  of  skimmed, 
parboiled  milk,  may  be  taken  with  cereal,  and  if  desired  a  small  quantity  of 
powdered  sugar  used.  1  zwieback  with  a  thin  layer  of  fresh  butter,  4  ounces  of 
parboiled  skimmed  milk,  containing  half  volume  of  lime-water,  served  warm,  and 
flavored  with  cofl'ee,  cocoa,  caramel  or  vanilla. 

9.30  A.  M.  Six  ounces  of  thin  water  gruel  from  cereals  or  fresh  vegetables, 
strained  and  served  hot,  1  rusk  or  zwieback,  or  dry  toast. 

11.30  A.M.  Four  ounces  of  malted  milk,  whipped  egg  with  parboiled  milk, 
corn-starch  pudding,  simple  custard  lightly  cooked. 

12.30  P.M.  Six  ounces  potato,  pea,  bean,  or  asparagus  puree  (strained)  or 
vegetable  broth;  4  ounces  of  Salisbury  steak  (moderately  well  cooked)  to  chew; 
2  ounces  (cooked  weight)  of  thin  rice,  sago,  tapioca,  or  corn-starch  pudding  made 
with  parboiled  milk  and  egg  yolk;  2  ounces  of  parboiled  milk  and  small  quantity 
of  pulverized  sugar  may  be  eaten  with  the  pudding;  1  rusk  or  zwieback,  6  ounces 
of  parboiled  milk  and  quarter  volume  of  lime-water  flavored  to  taste. 

4  P.  M.  Four  ounces  of  water  gruel  from  cereals,  1  very  soft  poached  egg,  1 
rusk  or  zwieback,  4  ounces  of  hot  Vichy  water. 

6  p.  M.  Four  ounces  of  whipped  egg,  2  rusks  or  zwieback,  6  ounces  of  malted 
milk  (thin),  flavored  to  taste,  or  cereal  water  gruel  or  parboiled  milk  and  quar- 
ter volume  of  lime-water  gruel. 

9  p.  M.  Six  ounces  of  water  cereal  gruel  or  4  ounces  of  malt  marrow,  2 
graham  crackers.     Calories  approximately   1500. 

Daijs  21  to  42. 

6.30  A.  M.     Two  teaspoonsful  of  phosphate  of  soda  in  a  glass  of  hot  water. 

8  A.  M.  Juice  of  1  sweet  orange  or  half  sweet  grapefruit,  or  boiled  prunes 
passed  through  fine  colander;  2  oimces  (cooked  weight)  of  thin  cereals  (cream 
of  wheat,  farina,  oatmeal,  corn  meal),  2  ounces  of  skimmed  milk  and  small 
amount  powdered  sugar,  1  soft  poached  egg,  2  zwieback,  2  rusks  or  2  thin  slices 
of  well  toasted  graham  bread,  1  pint  of  hot  skimmed  milk,  a  quarter  volume  of 
lime-water  flavored  to  taste   (cocoa,  vanilla,  etc.). 

10  A.  M.  One  pint  of  hot  parboiled  whole  milk  and  fifth  volume  of  lime-water, 
2  rusks  or  graham  crackers. 

12.30  noon.  Four  ounces  of  creamed  soup  from  vegetables,  strained,  6  ounces 
rare  meat  to  chew,  4  ounces  Avell-mashed  potato  or  baked  potato  (mealy  inside), 
or  carrot,  peas,  beans,  cauliflower,  Brussels  sprouts,  or  asparagus  (all  vegetables 
passed  through  a  strainer  and  served  with  15  grams  of  butter)  ;  4  ounces  (cooked 
weight)  of  pudding  from  rice,  corn-starch,  sago,  tapioca,  cream  of  wheat,  or  farina 
or  four  ounces  of  custard,  pulp  of  sweet  orange,  grapefruit,  or  prune  whip,  or 
chew  6  ounces  of  watermelon  or  cantaloup,  half  pint  of  hot  skimmed  milk. 

3.30  P.  M.  One  hundred  and  fifty  c.c.  of  hot  whole  milk  and  quarter  volume 
of  lime-water  or  150  c.c.  of  malted  milk  or  weak  cocoa. 

6.30  P.  M.  Two  rusks  or  zwieback  or  2  slices  of  well-toasted  graham  bread,  2 
very  soft  poached  eggs,  100  grams  of  sweet-apple  sauce  or  1  baked  apple  (omit 
skins),  or  juice  of  sweet  orange  or  half  of  grapefruit  or  chew  6  ounces  of  melon, 
1  pdnt  of  skimmed  milk  hot. 


GASTJilC  hemorriiaue  461 

'J  p.  M.  Two  lunulred  and  lifty  o.f.  of  whole  pai'boiled  milk  and  quarter  volume 
of  lime-water  of  25U  c.c.  of  malted  milk,  hot.  Caloriea  for  twenty-four  hours 
approximately  2000. 

General  Diet  After  Three  MuntJis.     If  distress,  patient  should  go  back  to  7  to  21 

day  diet. 

7  A.  M.     One  pint  of  skimmed  milk  and  half  gill  of  crean^. 

!)  A.  M.  Two  pieees  of  toast  without  butter,  juice  of  one  sweet  orange  or 
grapefruit  or  ripe  melon  or  apple  sauce  or  baked  apple  (do  not  eat  skin)  or 
marmalade,  1  dish  or  well-cooked  cereal  (oat-meal,  farina  or  cream  of  wheat), 
2  very  soft  poaclied  eggs,  2  cups  of  liot  sweetened  water.  The  water  may  be 
made  more  palatable  by  flavoring  with  cocoa,  tea,  coll'ee  or  cream. 

11  A.  xt.     One  cup  of  bouillon   (two  cubes),  two  graham  crackers. 

1  p.  XI.  This  should  be  heavy  meal  of  the  day.  It  may  consist  of  meat 
I  rare  beef  or  rare  iiamburger  steak,  lamb  or  white  meat  of  fowl),  fish  (never 
fried),  oysters,  well-cooked  spinach,  cauliflower,  carrots,  squash,  peas  (hulled), 
string  beans,  Brussels  sprouts,  baked  or  mashed  potatoes  (in  moderation),  rice 
with  gravy,  simple  puddings  made  from  cereals,  corn-starch,  gelatin,  well- 
cooked  fruit  sauces,  simple  cakes,  no  white  bread  (all  bread  should  be  made 
from  dark  Hour  and  should  be  at  least  one  day  old),  1  pint  of  skimmed  milk 
taken  hot. 

4  P.M.  One  glass  of  hot  peppermint  water  (20  drops  of  "essence"  of  pepper- 
mint to  the  glass),  sweeten  to  taste  and  drink  slowly,  two  graham  crackers. 

7  P.  M.  A  light  lunch  consisting  of  vegetable  soup,  simple  salad,  toast,  soft 
eggs,  and  plain  puddings  or  cake,  with  or  without  ripe  cooked  fruit  sauces,  -1 
pint  of  hot  skimmed  milk. 

Bedtime.  One  glass  of  malt  marrow,  malted  milk  or  hot  skimmed  milk. 
Calories  approximately  3500  for  twenty-four  hours. 

Einhorn's  method  of  duodenal  alimentation  already  described  is 
a  most  useful  and  feasible  method  of  feeding  in  severe  forms  of  gastric 
ulcer,  not  yielding  to  other  forms  of  treatment.  By  means  of  this 
method  it  is  possible  to  nourish  the  individual  without  great  loss  of 
flesh. 

Einhorn  uses  as  a  nutritive  medium  a  mixture  of  200  to  2-40  c.c.  of 
milk,  1  egg,  15  to  30  gm.  of  lactose  every  two  hours.  At  times  he  adds 
cream  to  increase  the  caloric  value. 

In  some  cases  his  diet  for  duodenal  feeding  consists  of— 


7. .30  A.  ir. :     Oatmeal  gruel  .  .  .  180  c.c. 

One  egg. 

Butter     15  gm. 

Lactose 180  c.c. 

9.30  A.  M. :     Pea  soup    180  c.c. 

One  egg. 

Butter     15  gm. 

Lactose   15  gm. 

11.30  A.M.:      Same  as  9.30  a.m. 
1.30  p.  M. :     Bouillon   180  c.c. 

One  egg. 
3.30  p.  M.:     Oatmeal  gruel   .  .  .  180  c.c. 

Butter     15  gm. 

One  egg. 

Lactose 15  gm. 


5.30  p.  M. :     Pea  soup    180  c.c. 

Butter     15  gm. 

One  egg. 

Lactose   15  gm. 

9.30  p.  M. :      Bouillon   180  c.c. 

One  egg. 
Total  quantity: 

Oatmeal  gruel   .  .  .  360  c.c. 

Pea  soup    720  c.c. 

Eggs    8 

Lactose   90  gm. 

Bouillon    360  c.c. 

Butter     90  gm. 


GASTRIC  HEMORRHAGE 

As  soon  as  hemorrhage  from  the  stomach  occurs,  the  patient  should 


462  DIET  IN  DISEASE 

be  put  to  bed  and  not  allowed  to  rise,  even  for  purposes  of  defecating 
or  urinating.  A  light  ice-bag  should  be  placed  over  the  region  of  the 
stomach,  and  no  food  or  drink  whatever  should  be  allowed ;  in  order 
to  quench  the  thirst  small  quantities  of  ice  may  be  given  the  patient 
to  suck.  Nourishment  must  be  entirely  by  the  rectum;  but  even  this 
is  usually  unnecessary  for  the  tirst  few  days.  In  order  to  combat 
the  weakness  following  great  loss  of  blood  salt  solutions  may  be 
injected  into  the  rectum,  or  if  the  patient  is  very  weak,  coffee,  meat- 
juice,  or  whisky  may  be  added  to  the  enema.  In  very  grave  cases 
salt  infusions  must  be  resorted  to,  administered  by  subcutaneous  or 
intravenous  injections. 

The  salt  solution  enema  is  often  best  given  in  the  form  of  a  pro- 
longed instillation  by  tha  drop  method.  After  a  few  days  nourish- 
ment may  be  given  by  means  of  nutrient  enemata,  or  by  the  con- 
tinuous feeding  per  rectum  by  the  drop  method. 

Bourget  has  advised  his  iron  chlorid  gelatin  in  cases  of  gastric 
hemorrhages.  This  mixture  is  prepared  as  follows:  100  grams  of 
gelatin  are  dissolved  by  moderate  heat  in  100  grams  of  glycerin  and 
100  grams  of  water ;  when  thoroughly  liquefied,  50  grams  of  tincture 
of  chlorid  of  iron  is  quickly  added.  A  precipitate  is  formed  by 
coagulation,  the  entire  mass  is  heated  gradually,  and  stirred  until  it 
is  homogeneous ;  it  is  then  allowed  to  run  over  metal  plates  divided 
into  small  squares  of  one  centimeter.  Two  or  three  tablets  are  taken 
several  hours  after  meals.  Bourget  orders  the  following  diet  in  gas- 
tric hemorrhage : 

Milk  and  rolls. 

Chlorid  of  iron  gelatin  tablets. 

100  to  100  c.c.  of  Boiirget's  alkaline  Avater  (8  gm.  sodium  bi- 
carbonate, 4  gm.  sodium  phosphate,  and  2  gm.  sodium  sul- 
phate in  each  liter ) . 

Milk  with  rice. 

Chlorid  of  iron  gelatin  tablets. 

150  c.c.  alkaline  water. 

Milk  and  rice. 

Chlorid  of  iron  gelatin  tablets. 

100-150  c.c.  alkaline  water. 

In  some  hemorrhages  Bourget  administers  the  gelatin  only  after 
lavage  of  the  stomach  with  a  1  per  cent,  chlorid  of  iron  solution.  The 
results  following  the  treatment  are  most  favorable. 

Hot-water  enemata  have  also  been  employed  for  the  control  of 
gastric  and  duodenal  hemorrhage.  A  pint  of  water  at  a  temperature 
of  120°  F.  is  administered  three  times  daily;  this  is  said  to  cause  a 
reflex  anemia  in  the  upper  intestine,  and  this  acts  favorably  on  the 
hemorrhage. 

Kemp  also  advises  the  administration  of  gelatin  in  gastric  hemor- 
rhage. He  orders  1  to  2  drams  of  a  5  to  10  per  cent,  solution  of 
sweetened  gelatin  given  cold  every  half  hour  for  10  to  12  hours  even 


8 

A. 

M.: 

10 

A. 

M. : 

10.30 

A 

.  M. : 

12 

A. 

M.: 

3 

P. 

m'.  : 

3.20 

to  4 

P. 

M. : 

6 

P. 

M.: 

9 

P. 

M.: 

10 

P. 

M.: 

DIF.T  7.Y  CARCiyOMA  OF  THE  STOMACH  463 

if  there  be  vomiting;  after  this  the  gelatin  is  contined  in  i/^  to  1  oz. 
doses  every  2  to  3  hours  in  addition  to  the  albumin  of  2  raw  eggs 
beaten  up  and  placed  in  a  cup  on  ice  and  given  in  divided  portions. 
Gelatin  treatment  is  continued  for  a  week.  The  gelatin  may  also  be 
used  as  an  enema  in  1  to  2  per  cent,  solutions,  or  it  may  be  taken  in- 
ternally, a  tablespoonful  of  a  10  per  cent,  solution  being  given  every 
three  hours. 

After  the  cessation  of  the  hemorrhage  for  a  few  days  feeding  by 
mouth  may  be  instituted,  beginning  with  small  amounts  of  milk  and 
gradually  increasing  in  quantity. 

DIET  IN  CARCINOMA  OF  THE  STOMACH 

Boas  divides  the  treatment  of  cancer  of  the  stomach  into  the  treat- 
ment of  cancer  of  the  cardiac  portion  of  the  stomach  and  that  of  the 
body  of  the  stomach. 

In  the  treatment  of  cancer  of  the  cardiac  portion  of  the  stomach 
the  diet  should  be  such  as  will  prevent,  so  far  as  possible,  any  irrita- 
tion of  the  diseased  and  stenosed  esophagus  and  stomach.  Solids 
should,  therefore,  be  avoided.  Milk  is  the  food  that  is  usually  best 
borne  in  this  disease.  It  can  be  rendered  more  nutritious  by  the 
addition  of  somatose.  Nestle  "s  food,  eggs,  and  the  like.  Besides  this, 
broths  of  all  kinds,  cocoa,  milk  with  tea  or  coffee,  or  buttermilk  may 
be  given.     ^Nlehring's  Vigor  Chocolate  is  useful  for  supplying  fat. 

As  soon  as  difficulty  arises  in  swallowing  liquids,  gastrotomy  should 
be  performed,  in  order  to  supply  the  nourishment  which  it  is  impos- 
sible to  pass  in  through  the  esophagus.  If  this  procedure  is  deemed 
inadvisable,  nutrient  enemata  may  be  resorted  to. 

In  the  dietetic  treatment  of  cancer  of  the  body  of  the  stomach 
milk  likewise  forms  the  most  important  article  of  diet.  The  more 
easily  digestible  forms  of  meat,  such  as  sweetbreads,  scraped  beef, 
brains,  and  stewed  chicken,  are  permissible.  In  this  disease  there  is 
usually  a  distaste  for  meat,  and  fish  may  be  substituted  for  it;  of 
these,  boiled  mackerel,  rock,  haddock,  or  trout  are  to  be  recommended. 
Of  the  vegetables,  mashed  potatoes,  spinach,  carrots,  peas,  beans, 
cauliflower,  if  mashed  and  strained  so  as  to  rid  them  of  cellulose,  are 
admissible;  rice,  farina,  and  cornstarch  with  milk  are  also  valuable 
forms  of  food. 

In  cases  of  cancer  of  the  stomach  too  abundant  a  diet  should  not 
be  insisted  upon,  as  at  best  but  little  can  be  gained  by  this  method  of 
treatment. 

Milk  with  tea,  coffee  or  cocoa,  or  wine  or  whisln',  may  be  given  for 
the  thirst.  The  food  value  of  these  liquids  may  be  increased  by  the 
addition  of  preparations  such  as  somatose,  nutrose,  etc.  Fluids 
should,  however,  be  taken  in  small  quantities  at  a  time.  In  order  to 
supply  the  necessary  quantity  of  fat,  butter  or  Mehring's  Vigor 
Chocolate  is  to  be  recommended.     In  these  cases  it  is  often  important 


464 


DIET  IX  DISEASE 


to  promote  the  general  nutrition  by  means  of  rectal  alimentation. 
The  taste  of  the  patient  should  be'  consulted  in  prescribing  the  diet 
in  this  disease,  and  various  delicacies  to  tempt  the  appetite  should  be 
served,  care  being  taken  to  avoid  monotony  in  food  and  endeavoring 
to  overcome  the  distaste  for  it.  It  is  possible  often  by  careful  atten- 
tion to  the  diet  to  maintain  a  good  state  of  nutrition  in  these  patients 
for  a  considerable  period  of  time. 

Diet-list  for  Cancer  of  the  Stomach,  as  given  by  Boas. 

Calories. 

8  A.M.:        100  gin.  milk  and  tea    (07.5),   50  gm.   zwieback    (174.8),    10 

gm.  butter   (71.3)    336.60 

10  A.  M.:        100  gm.  broiled  perch   71.80 

50  gm.  toasted  bread    129.90 

or   100  gm.  calves'  brain    (140),  sweetbread    (90),  2  eggs 
(160). 

12  o'clock :    150  gm.  milk  and  rice   260.00 

100  gm.  veal    142.45 

50  gm.  macaroni    126.30 

3  P.  M. :        100  gm.  tea  and  milk  ( G7.5 ) ,  50  gm.  cakes   ( 187 )    254.50 

7  P.  M. :        100  gm.  cream    214.60 

50  gm.  zwieback,  10  gm.  butter  (71.3).  30  gm.  ham  (131)  ..  .  376.30 

9  P.  M. :         50  gm.  cream 107.30 

Total    2016.75 

Diet-list  of  Wegele  for  Cancer  of  the  Stomach. 

Albumin       Fat        Carbo-      Alco- 
Aibumin.      tat.    iiydrates.     hoi. 

Morning:                150  gm.  maltoleguminose  cocoa    ....      G.O  4.00  13.5 

Forenoon:              200  gm.    kefir    6.6  4.50  3.8         1.0 

Noon:                      150  gm.  maltoleguminose  soup   4.0  0.150  9.3 

100  gm.  scraped  beef  20.0  6.00 

Afternoon:             150  gm.  maltoleguminose  cocoa    ....      6.0  4.00  13.5 

Evening:                 100  gm.  scraped  ham    25.0  8.00 

150  gm.  tapioca    7.0  5.00  8.0 

10  o'clock:             '^00  gm.   kefir    6.6  4.50  3.8         1.0 

with  the  cocoa,  30  gm.  honey 0.4  ...  22.0 

with  the  kefir,  20  gm.  cognac ...  ...        14.0 

During  the  day:      50  gm.    zwieback    6.6  1.00  35.0 

Total     87.6       37.15     108.9       16.0 

Calories    360  350        450        100 

Entire   number   of   calories    1260 


Cohnheim's  Dietary  in  Cases  of  Gastric  Cancer. 

7  A.  M. :     Milk  soup,  cooked  with  cream  and  butter.     Biscuits  with  butter. 
9.15  A.M.:     Tea  and  cream,  butter  rolls,  scraped  ham,  and  a  soft  egg. 

12  M. :     Rice   broth   or   soup;    puree   of   spinach,   carrots,   or   peas;    chopped 
chicken,  broiled  calves'  brains  or  fish;  and  some  sweet  fruit  sauce. 
3  P.  M. :     Cocoa  with  cream  and  butter  cakes. 
5.30  P.M.:     A  cereal  soup  or  broth,  containing  much  butter. 
7.15  P.  M. :     Tea  with  plenty  of  cream,  scraped  ham,  and  butter  rolls. 
Ziceig's  Diet  in  Gastric  Carcinoma. 

Calories. 

Breakfast:  l  liter  milk;  40  gm.  toast;  10  gm.  butter 504.0 

Luncheon :  Oatmeal  soup ;    15  gm.  puree   90.0 

Noon  (dinner)  :  Vegetable  green  soup,  1  yolk  of  egg;  150  gm.  roast 
beef,  game,  fowl  or  fish,  finely  hacked ;  40  gm. 
toast;   100  gm.  mashed  potatoes   667.4 


DIET  IN  GASTR0PT0SI8  AND  ENTER0PT08I8  465 

Afternoon:  i  liter  milk  cocoa,  1  yolk  of  egg;  30  gm.  zwieback...      400.0 

Evening  (supper)  :    Flour  milk  gruel,  viz.,  250  gm.  milk,  20  gm.  tapioca, 

oatmeal,  or  mondamin,  15  gm.  sugar;  50  gm.  toast.     320.0 

1981.4 

The  authors  have  found  the  following  diet-list  useful  in  many  cases 
of  cancer  of  the  stomach: 

Calories. 

8  A.  M. :      150  gm.   milk  with   tea    100.0 

50  gm.    toast    130.0 

10  A.  M. :      100  gm.    baked    trout    106.0 

100  gm.  milk  or  30  gm.  Panopepton   (57.5)    67.0 

10  gm.   butter    81.0 

50  gm.   toast    130.0 

50  gm.  sherry    60.0 

12  M. :      bouillon  with  5  gm.  somatose  16.0 

100  gm.   chicken 106.0 

or  100  gm.  calves'  sweetbread    (90) 
or  100  gm.  calves'  brains   (140) 
or  100  gm.  sqiiab  (100) 

60  gm.   macaroni     212.0 

100  gm.  mashed  potatoes   127.0 

or   100  gm.  spinach    (166) 
or  100  gm.  asparagus  (18) 

25  gm.  stale  wheat  bread 65.0 

4  P.  M. :        50  gm.    toast    130.0 

20  gm.   butter    162.0 

40  gm.   caviare    52  0 

7  P.M.:      150  gm.  milk   (100)  with  5  gm.  somatose  (16)    ...  116  0 

100  gm.  rice  cooked  in  milk   177.0 

50  gm.  wheat  bread   130.0 

9  P.  M. :       30  gm.   Panopepton    57.5 

2024.5 

DIET  IN  GASTROPTOSIS  AND  ENTEROPTOSIS 

While  the  treatment  of  gastroptosis  and  enteroptosis  is  mainly 
mechanical, — requiring  the  use  of  well-titting  abdominal  bandages, 
massage,  and  electricity, — much  can  be  accomplished  by  proper  care 
in  the  diet.  Remarkable  results  are  frequently  obtained  from  rest 
cures,  the  patient  being  compelled  to  remain  in  the  recumbent  position 
for  a  long  period  of  time  and  to  take  large  quantities  of  food.  This 
form  of  treatment,  resorting  at  times  to  forced  feeding  or  a  food  cure, 
is  especially  necessary  in  individuals  who  have  become  greatly  emaci- 
ated. Patients  afflicted  with  these  conditions  should  lie  down  after 
eating.  The  diet  should  be  very  nourishing,  and  should  contain  some- 
what large  proportions  of  fatty  foods.  Milk  is  an  excellent  food  in 
many  cases,  and,  where  it  is  well  borne,  cream  may  be  added  to  it  to 
increase  its  caloric  value,  and  may  be  taken  in  large  quantities.  When 
milk  is  not  well  borne,  solid  foods  must  be  administered.  Of  these, 
all  forms  of  digestible  meats  can  usually  be  allowed,  such  as  chicken, 
roast-beef,  broiled  steak,  and  lamb-chops;  fish  of  various  kinds  and 
digestible  vegetables  are  also  permissible ;  of  the  vegetables  especially 
to  be  recommended  are  spinach,  carrots,  asparagus,  and  cauliflower; 
30 


466  DIET  IN  DISEASE 

of  the  fats,  butter,  cream,  and  Mehring's  Vigor  Chocolate  are  par- 
ticularly useful. 

In  order  to  overcome  the  severe  constipation  accompanying  these 
conditions,  foods  that  excite  intestinal  peristalsis  are  especially  to  be 
recommended ;  among  these  may  be  mentioned  cider,  buttermilk,  grape- 
juice,  fruits,  and  honey.  The  object  of  the  so-called  forced  feed- 
ing or  food  cure  is  to  increase  the  body-weight  until  it  corresponds 
with  the  weight  of  the  individual  in  health.  Boas  advises  that  the 
patient  be  kept  in  bed  for  four  to  five  weeks,  a  varied  diet  being 
insisted  on,  and  nourishment  supplied  every  two  hours.  Boas  be- 
lieves that  better  results  are  obtained  if  instead  of  administering 
large  quantities  of  milk,  cream  (from  i/o  to  1  liter  daily)  be  given  in 
quantities  of  from  150  to  200  c.c. 

Strauss  reports  favorable  results  from  the  following  alimentation 
as  a  food  cure  in  enteroptotic  and  neurasthenic  patients : 

Breakfast:       Flour   soup   rich    in   butter,   porridge,   cocoa   with    milk-and-cream 

mixture,  egg,  and  some  buttered  rolls. 
Dinner:  Dishes  made  of  flour  and  eggs  and  cream. 

ICrackers  with  milk-cream  mixture,  zwieback,  and  butter. 
Afternoon :     J 

Supper:  Should  consist  of  the  rich  flour  soups,  or  dishes  made  from  flour 

and  eggs,  with  a  beverage  of  tea  and  milk-cream  mixture. 

Before  going  to  bed  the  patient  is  permitted  a  glass  of  milk-cream 
mixture.  In  addition,  side-dishes  of  malt-extract  and  fruit-juices 
may  be  permitted. 

Zweig's  Food  Cure  Diet  in  Cases  of  Enteroptosis. 

Calories. 
8.00  A.M.:         i  liter  of  milk,  with  tea, 
50  gm.  white  bread, 
20  gm.  butter, 

30  gm.    honey    680 

10.00  A.M.:         i  liter  kefir   (one  day  old), 
50  gm.  Graham  bread, 

20     gm.  butter   420 

12.30  noon:     150  gm.  meat  or  fish, 
250  gm.  vegetables, 
50  gm.  apple-sauce, 

1  omelet  from  two  eggs, 
10  gm.  butter, 
10  gm.  sugar, 

Fruit :   grapes,  oranges,  figs    900 

4.00  P.  M.:  1  liter  milk. 

6.00  P.  M. :         i  liter  milk  chocolate, 
50  gm.  Graham  bread, 
20  gm.  butter, 

Tablespoonf ul  of  honey    1020 

8.00  P.  M.:         2  eggs, 

100  gm.  meat,  fowl,  or  fish, 
50  gm.  preserves, 
100  gm.  vegetables, 
50  gm.  Graham  bread, 
20  gm.  butter. 

20  gm.  soft  cheese   1190 

i  liter  milk. 


DIET  I\  yERVOVS  GASTRIC  DISORDERS  467 

Calories. 
9.30  P.  M. :  I  liter  kefir. 

Total     4210 

DIET  IN  NERVOUS  GASTRIC  DISORDERS 

Nervous  Anorexia. — In  this  conditiou  it  is  important  to  isolate 
the  patient  from  his  family.  Milk,  in  gradually  increasing  quanti- 
ties, and,  if  possible,  other  foods,  should  be  given.  If  the  patient  does 
not  take  sufficient  nourishment,  nutrient  enemata  should  be  admin- 
istered, or  the  patient  may  be  fed  by  means  of  the  stomach-tube.  The 
food  should  be  given  in  as  concentrated  and  nutritious  a  form  as 
possible;  for  this  purpose  eggs  are  suitable.  Somatose  should  be 
added  to  the  milk.  Frequently  cases  of  anorexia  are  completely  cured 
by  a  well-regulated  rest  cure  of  from  six  to  ten  weeks'  duration. 
Excellent  results  are  obtained  by  duodenal  feeding. 

Nervous  Vomiting. — This  is  often  overcome  merely  by  isolation 
and  change  of  scene.  In  severe  cases  patients  should  be  placed  in 
bed;  they  are  best  fed  on  semisolid  or  liquid  food,  since  the  latter  is 
more  easily  retained  than  solid  food.  It  should  be  given  in  very 
small  quantities;  scraped  beef,  eggs,  rice,  and  toast  are  especially 
useful.  Cracked  ice  will  often  afford  relief.  The  most  indigestible 
forms  of  foods  are  frequently  well  borne  when  the  most  digestible 
are  speedily  vomited.  In  severe  cases  the  patient  should  be  fed  for 
some  days  exclusively  by  rectal  alimentation  or  duodenal  feeding 
should  be  practised.  The  most  gratifying  results  are  obtained  by 
means  of  the  last-mentioned  form  of  treatment. 

Nervous  Subacidity  and  Anacidity. — The  food  should  be  given 
in  small  quantities  and  frequently.  The  diet  need  not  be  limited  to 
carbohydrate  food,  but  should  be  a  mixed  one,  since  the  intestine 
takes  up  the  work  of  the  stomach  in  digesting  the  protein  food.  A 
more  extensive  description  of  the  diet  to  be  used  will  be  found  in  the 
section  on  the  Diet  in  Achylia  Gastrica. 

Diet  in  Nervous  Dyspepsia. — In  this  condition  the  diet  should  not 
be  too  restricted.  Strengthening  food,  without  any  attempt  at  a  too 
rigorous  diet,  should  be  prescribed.  The  patient  must  be  impressed 
with  the  idea  of  the  importance  of  consuming  as  much  food  as  pos- 
sible. In  those  eases  in  which  milk  is  well  tolerated  it  should  be  given 
in  large  quantities;'  when  it  is  not  well  borne,  buttermilk,  kefir,  or 
kumiss  may  be  substituted  for  it.  The  patient's  appetite  should  be 
humored,  and  he  should  be  allowed  to  eat  any  food  he  can  digest. 
Alcoholic  stimulants  should  be  prohibited,  or  given  only  in  very  small 
quantities.  In  severe  cases  a  well-conducted  rest  cure  will  produce 
the  best  results;  but  often  change  of  scene,  relief  from  cares,  or  ex- 
ercise in  the  open  air  will  bring  about  a  cure. 

Diet  as  Recommended  by  Burkart  for  Nervous  Dyspepsia. 
(For  the  first  six  days  of  treatment.) 
7.30  A.M.:     i  liter  milk  and  2  zwieback. 
10  A.M.:     1  liter  milk  and  1  zwieback. 


L2.30 

P. 

M.: 

3.30 

p. 

M. : 

5.30 

p. 

M.: 

8 

P. 

M. : 

468  DIET  IX  DISEASE 

A  plate   of   soup  with    1   egg,   50  gm.   broiled   meat,  and   mashed 

potatoes. 
i  liter  milk  and  1  zwieback. 
i  liter  milk  and  2  zwieback. 
I  liter  milk,  50  gm.  broiled  meat,  with  bread  and  butter. 

Total  calories  4600. 

Diet  as  Recommended  by  Burlcart  for  yervoiis  Dyspepsia. 
( For  ninth  to  fifteenth  day  of  treatment. ) 

7.30  A.  M. :  J  liter  milk  and  2  zwieback. 

8.30  A.  u. :  Coffee  and  cream,  bread  and  butter. 

10  A.  M. :  J  liter  milk  and  2  zwieback. 

12  M.:  i  liter  milk. 

1  P.  ii. :  Soup  with  egg,  100  gm.  meat,  mashed  potatoes,  75  gm.  prunes. 

3.30  P.  M. :  i  liter  milk. 

5.30  p.  M. :  1  liter  milk,  2  zwieback. 

8  P.  M. :  I  liter  milk,  60  gm.  bread  and  butter. 

9.30  P.  M. :  ^  liter  milk,  2  zwieback 

Diet  as  Recommended  by  Burkart  for  yervous  Dyspepsia. 
(After  the  fifteenth  day.) 

Protein.        Fat.       ^^Carbo^^ 

7  A.  M. :     500  gm.    milk    17.0  18.2         24.0 

small  cup  of  coffee  or  tea   (20  gm.  cream)    . .        0.7  5.0  0.7 

80  gm.    cold   meat    30.8  2.0 

8  A.  ii. :     Milk-toast      4.5  0.5         29.0 

20  gm.  butter    0.3  16.6  0.1 

100  gm.  baked  potatoes    1.8  10.0  25.0 

10  A.  ir. :     300  gm.   milk    10.2  10.9  14.4 

Xoon:          300  gm.   milk    10,2  10.9  14.4 

200  gm.    soup    2.2  4.0  11.4 

200  gm.  beef    76.4  5.4 

1  p.  M. :     200  gm.  potatoes    6.2  1.7  42.6    ' 

125  gm.  prunes     0.4  ...  8.3 

200  gm.  of  farinaceous  food  of  any  kind.  .  .  .  12.8  21.2  45.0 

3  30  p.m.:     500  gm.   milk    '. 17.0  18.2  24.0 

300  gm.   milk    10.2  10.9  14.4 

5  30  P.  M. :       80  gm.  cold  meat   30.8  2.0 

Milk-toast   4.5  0.5  29.0 

20  gm.  butter   0.3  16.6  0.1 

8  P.  M. :       80  gm.  broiled  meat    30.8  2.0 

40  gm.    zwieback    0.0  5.2  33.2 

500  gm.   milk    17.0  18.2  24.0 

9.30  P.  M. :     500  gm.   milk    17.0  18.2  24.0 

20  gm.  zwieback  0.3  2.6  16.6 

295.0       199.8       380.2 

Diets  in  Xervous  Dyspepsia  as  Advised  by  Boas  as  a  Fattening  Cure. 

7  A.  M. :     i  liter  chocolate  with  cream,   3   to  4   zwieback  or   rolls,   20  to   30 

grams  of  butter. 
10  A.  M. :     Cold  or  warm  meat,  eggs,  egg  dishes,  wheat  bread,  20  grams  butter, 
150  grams  cream,  preserves,  or  stewed  fruit. 
1  p.  M. :     i  liter  soup,  potatoes,  or  other  vegetables  in  puree  form,   meat   or 
fish,  salad,  stewed  fruit  (sweet),  or  raw  fruits. 
4.30  p.  M. :     Coffee  or  tea  with  cream,   150  grams  zwieback,  crackers,  butter,  20 
grams  of  honey. 

8  p.  M:    Egg  or  egg  dishes,  wheat  bread,  Graham  bread,   butter   30  grams, 

stewed    fruit,    two    glass   of   fruit    wine,    or    one   bottle   of   malt 
beer. 


DIET  IN  IIYPERCHLORHYDRIA  OR  HYPER  AVIDITY  469 

9.30  P.M.:    200   grams   cream,   with   two   to   three   crackers,   or    zwieback   with 
butter. 

In  this  diet  cream  is  used  instead  of  milk,  the  chief  dependence 

being  placed  upon  the  digestible  fats. 

DIET  IN  HYPERCHIORHYDRIA  OR  HYPERACIDITY 

By  the  term  hyperchlorhydria  is  meant  an  increase  in  the  secretion 
of  muriatic  acid  in  the  stomach.  In  the  treatment  of  this  condition 
the  main  object  is  to  prevent  this  increase  in  acid;  this  is  best  ac- 
complished by  regulation  of  the  diet.  All  irritating  fluids,  such  as 
acids,  including  organic  acids,  as  acetic  (vinegar),  citric,  and  tartaric 
acids,  spices  or  condiments  (pepper,  mustard,  vinegar),  should  be 
avoided,  and  the  use  of  all  strong  alcoholic  beverages  and  of  hard 
substances,  which  are  apt  to  irritate  the  stomach,  such  as  nuts,  should 
be  interdicted.  Food  must  be  thoroughly  masticated,  and  should  be 
taken  neither  too  cold  nor  too  hot.  The  class  of  foods  that  seem  to 
be  best  suited  are  the  proteins,  since  they  combine  with  and,  therefore, 
neutralize  the  excess  of  acid ;  for  this  reason  foods  containing  an 
abundance  of  protein,  such  as  eggs,  meat,  and  fish,  may  be  given  quite 
freely.  The  large  amount  of  extractives  in  meat  stimulate  the  flow  of 
gastric  juice,  and,  therefore,  meat  should  be  allowed  only  when  well 
cooked,  so  as  to  remove  the  extractives.  For  the  same  reason  raw 
beef  and  beef-juice  should  be  avoided  in  this  condition.  Carbo- 
hydrates should  be  administered  in  small  quantities  and  in  the  most 
digestible  forms. 

BickeVs  Diet  List,  Presenting  the  Food  which  Slightly  and  the  Food  which 
Strongly  Excites  Gastric  Secretion 

Foods  slightly  exciting  acid  secretion. 

Liquids:  Water,  alkaline  water  tea,  cocoa  (rich  in  fats),  milk  (rich  in  fats), 
cream,  and  egg-albumen 

Condiments:     0.9  per  cent,  of  salt  solution. 

Solids:     Cooked  meats,  fats  of  all  kinds,  cooked  vegetables,  such  as  potatoes, 
asparagus,  cauliflower,  spinach,  white  beets   (all  in  puree),  starch,  sugar. 
Foods  strongly  exciting  acid  secretion. 

Liquids:  All  alcoholic  and  carbonated  drinks,  coffee,  cocoa  (poor  in  fats), 
skimmed  milk,  beef-tea,  beef  extract,  strongly  seasoned  soups,  yolk  of  eggs, 
hard-boiled  eggs,  beef  solution. 

Condiments:  Pepper,  cinnamon,  mustard,  cloves,  paprika,  salt  in  concentra- 
tion. 

Solids:  Eaw  or  slightly  cooked  beef,  dark  meats,  salted  meats  (pork,  pickled 
meats,  smoked  fish),  dark  breads. 

Fleischer  has  investigated  the  subject  of  the  combining  effect  of 
muriatic  acid  with  various  foods;  he  discovered  that  beef,  veal,  ham, 
and  mutton  bind  twice  as  much  muriatic  acid  as  do  calves'  brains  and 
sweetbreads ;  the  first-named  class  of  meats  are,  therefore,  most  suita- 
ble in  conditions  of  hyperchlorhydria.  Inasmuch  as  uncooked  meats 
tend  to  excite  the  flow  of  the  gastric  juice,  they  should  not  be  taken 
in  this  condition;  when  meat,  however,  is  well  cooked  it  may  be 
prescribed  to  advantage  in  conditions  of  hyperchlorhydria.     In  addi- 


470 


DIET  IX  DISEASE 


tion  Fleischer  mentions  the  following-  articles  of  foods  capable  of 
binding  large  quantities  of  muriatic  acid :  pork,  cheese,  sausage,  ham. 
Graham  bread,  milk,  and  cocoa.  Farinaceous  foods  are  not  well 
tolerated  in  this  condition,  and  must  be  given  either  in  a  very  digesti- 
ble form  or,  best,  combined  with  protein  food.  Only  the  more  digesti- 
ble vegetables  are  to  be  allowed,  such  as  mashed  potatoes,  spinach, 
asparagus,  peas,  and  carrots,  strained  and  eaten  in  the  form  of  purees. 
Fats  tend  to  lessen  the  acidity  of  the  gastric  secretion,  and  are.  there- 
fore, to  be  recommended;  they  are  best  given  in  the  form  of  butter, 
cream,  olive  oil,  and  the  like.  Of  the  fluids,  alkaline  mineral  waters, 
such  as  ApoUinaris,  Vichj*,  and  Seltzer,  are  especially  useful;  the 
carbon  dioxide  contained  in  these  waters  produces  a  sedative  effect 
and  lessens  the  secretion  of  acids.  These  waters  may  be  used  to  dilute 
milk  or  wine.  The  following  table,  taken  from  Fleischer,  shows  the 
ability  of  various  foods  to  combine  with  muriatic  acid : 

Fleischer's  Tahle,^  showing  the  Poicer  of  Foods  to  Combine  icith  UCl. 


Meats    (100  grams). 


Pure  HCl. 


Calves'  brains,  boiled   0.65 

Liver  sausage    0.80 

Calves'  thymus,  boiled   0.90 

Meat   sausage      ; 1.00 

Cervelat   sausage    1.10 

Blood    sausage 1  .-30 

Pork,  boiled    1.60 

Ham,   boiled    l.SO 

Ham,  raw    1.90 

Mutton  boiled 1.90 

Beef,  boiled   2.00 

Veal,  boiled   2.20 

Leube-Eosenthal  meat  solution   2.20 

Beer 0.10 

Milk   (analysis  of  different  kinds)    0.36 

White  bread    0.30 

Graham   bread    0.30 

Black  bread   ( gray  bread)    0.50 

Pumpernickel     0.70 

"Hand"   cheese    1.00 

Fromage  de  Brie   1.30 

Edam  cheese   1.40 

'"Backstein"   cheese    1.70 

Pea   sausage    1.70 

Roquefort     2.10 

Swiss  cheese    2.60 

Cocoa    4.10 


5  per  cent. 

Dilute 

HCl. 

muriatic  acid 

2.60 

5.20 

3.20 

6.40 

3.60 

7.20 

4.00 

8.00 

4.40 

8.80 

5.20 

10.40 

6.40 

12.80 

7.20 

14.40 

7.60 

15.20 

7.60 

15.20 

8.00 

16.00 

8.80 

17.60 

8.80 

17.60 

0.40 

0.80 

1.44 

2.80 

1.20 

2.40 

1.20 

2.48 

2.00 

4.00 

2.80 

5.60 

4.00 

8.00 

5,20 

10.40 

5.60 

11.20 

6.80 

13.60 

6.80 

16.80 

6.40 

16.80 

10.40 

20.80 

16.40 

32.80 

In  arranging  the  diet  for  patients  with  hyperchlorhydria  it  has 
been  found  best  in  the  authors'  experience,  in  dealing  with  patients 
taking  but  little  nourishment,  to  allow  them  to  eat  at  frequent  in- 
tervals; if,  however,  large  meals  are  consumed,  it  is  advisable  to 
permit  onh'  three  meals  a  day,  allowing  the  stomach  to  rest  during  the 
intervals. 


1  Krankheiten  d.  Speiserohr.,  d.  Magens.  u.  d.  Darmes,  1896,  p.  932. 


DIET  ly  HYPERCHLORHYDRIA  OR  H  Y/'EUACIDny  471 

In  marked  forms  of  nervous  liyperchlorhydria  a  pure'y  vegetable 
or  milk  and  vegetable  diet  has  been  recommended  by  certain  writers ; 
the  vegetables  should  be  eaten  in  the  form  of  purees. 

Laufer,  Vincent,  Enriquez,  and  others  attach  great  importance  to 
a  salt-free  diet  in  liyperchlorhydria,  believing  that  a  high  percentage 
of  muriatic  acid  may  be  reduced  by  a  diet  free  of  salt.  Zweig  comes 
to  similar  conclusions,  and  urges  a  salt-free  diet  in  the  treatment  of 
gastric  hyperacidity.     (See  Salt-free  Diet.) 

The  following  tables,  taken  from  Zweig,  indicate  the  percentage  of 
salt  found  in  some  forms  of  uncooked  and  cooked  food: 

I.     Raw  Food  Stuffs.  Percentage  of 

sodium  chlorid. 

Milk      0.15-  0.18 

Butter    ( unsalted)      0.02-  0.21 

Butter   ( salted )    1.0  -  3.0 

Hen's  egg   0.13-  0.21 

Yolk   0.039 

White     0.31 

Caviar    3.00-  6.18 

Meat     0.10-  0.20 

Calves'  brains    0.29 

Fresh-water  tisli    0.06-  0.12 

Sea  tisli   0.16-  0.41 

Smoked  beef,  sausage,  or  pickled  meats 1.85-20.95 

Pork     1.00 

Ham     1.85-  7.50 

Beef  extract   /. 1.4  -14.6 

Protein  preparations:     Raborat     0.006 

Plasmon    0.21 

Somatose    0.G6 

Fruits,  cereals,  flour,  vegetables,  salads   0.01-  0.10 

With  the  exception:      Sago    0.19 

Oatmeal    0.26-  0.29 

Lentils    0.13-  0.19 

Cauliflower     0.15 

Spinach     0.21 

Sauerkraut,  pickles   0.73-  1.45 

Tea  and  coffee 0.05-  0.15 

Wine  and  beer  contain  but  a  trace  of  salt. 

11.     Food  Already  Prepared. 

Estimated  in 
In  100  gm.  portions  for  a 

single  individual. 

Milk  soup   ....  0.7 

Milk  with  cereal   ....  1.7 

Eggs :      Poached     ....  0.5 

Scrambled     ....  2.4-2.7 

Bouillon     0.55-1.0 

Soup     0.35-0.90 

Sauce   0.7  -1.5 

Meat :      Fillet 

Roast  beef 

1.9-2.8 

Beefsteak     3  0 

Bread :     Zwieback     0.38 

Wheat  bread    0.48-0.7 


472  DIET  IX  DISEASE 

Rye  bread 0.75 

Cooked  vegetables :     Cauliflower,  puree  of 

potatoes,  green  salad  0.5-0.9 

Asparagus    2.7-3.5 

The  following  diet  has  been  used  with  advantage  by  the  authors  in 
cases  of  hyperchlorhydria : 

Calories. 

8  A.  M. :      200  gm.  milk  flavored  with  tea 135 

2  soft-boiled  eggs    160 

60  gm.   toast    154 

40  gm.   butter    326 

10  A.  M.:        50  gm.  sherry   (60)  with  1  egg  (80)    140 

12  M.:           100  gm.  chicken   (or  broiled  meat  of  some  kind)  106 

100  gm.  mashed  potatoes   127 

100  gm.   spinach    166 

or  100  gm.  asparagus   (185). 

100  gm.  stewed  apples    53 

or  100  gm.  stewed  prunes 44 

60  gm.  stale  wheat  bread   154 

4  P.  M. :       150  gm.  milk    100 

50  gm.  crackers     188 

5  gm.  butter 407 

7  P.  M. :       100  gm.  milk  flavored  with  tea  67 

soft-boiled  egg   80 

gm.   toast    130 

25  gm.   butter    203 

X  2470 


Diet-list  for  Patients  with  Gastric  Hyperacidity. —  (Biedert.) 


Grams      Grams      "^Itur:      Cal 


Grams 
Carbo- 


Protein.        Fat.       hydrates,   "^^e^" 
In  the  morning  between  7  and  8  o'clojk:     500  c.c. 

of  milk,  40  gm.  toast  20.3         18.4         55.8         483 

In  the  morning  at   10  o'clock:      70  gm.  of  broiled 

veal     (or    100    gm.    of    stewed    veal    without    the 

skin,  prepared  as  white  ragout)   or  beefsteak  or 

fowl,   30   gm.    of   toast,    1    egg,   2    zwieback    (20 

gm.)    J  of  a  liter  of  Avine   32.3         12.0         36.9         395 

Twelve    o'clock    noon:     French     soup,    with    yolk 

of  egg   4.0  9.2  7.7         134 

140    gm.    of    broiled    or    boiled    fowl,    roast    meat, 

gulyas  or  hache,  200  gm.  of  raw  meat  as  beef- 
steak, or  100  gm.  of  finely  chopped  boiled  beef  or 

fish    42.8         10.4  ...         272 

Asparagus    with    cream    gravy     (a    few    heads    of 

asparagus  and  half  a  spoonful  of  gravv)   20  gm. 

of  toast    ■ 2.2  1.2         16.4  87 

Omelet  souffle   12.1         18.3  9.6         259 

One  small  cup  of  black  coff"ee. 

In  the  afternoon  at  4  o'clock:     250  gm.  of  milk- 
cocoa,  3  zwieback    13.5         15.8         44.6         385 

In  the  evening  at  7  o'clock:     70  gm.  of  cold  meat 

with  100  gm.  of  meat-jelly,  20  gm.  of  toast 24.2  5.4         15.4         212 

20  gm.  of  Swiss  or  Dutch  cheese 5.4  6.1  0.5  81 

Total     156.8         96.8       136.9       2308 


DIET  IN  HYPERCHLORHYDRIA  OR  HYPERACIDITY 


473 


Diet-list  for  Hyperacidity. —  ( Wegele. ) 


Protein.       Fat. 


Morning:               100 gm.  tea  with  milk 3.4 

2  soft-boiled  eggs   12.0 

Forenoon :              100  gm.  raw  ham   25.0 

50  cream     2.0 

200  gm.  Aleuronat  meal  broth    ( 10 

gm.  Aleuronat  to  200  broth) 
or  250  gm.  oatmeal  brotli 

(20  gm.  oatmeal  to  250  broth)    .  .  10.2 

Noon:                     150  gm.  beefsteak  58.0 

200  gm.  mashed  potatoes   6.2 

100  gm.  white  wine  witli  Saratoga, 

Vichy  or  Biliner  water 

Afternoon :             100  gm.  tea    3.4 

150  gm.  cream 2.0 

Evening:                  50  gm.  cold  meat   60.2 

2  scrambled  eggs,  100  gm.  wine. 

At  meal  times:    100  gm.  Aleuronat  toast    28.3 

10  o'clock  at      1  ,^,^              .„  „  _ 

night:             J -^^ ^™-  ^^^^   ^-^ 

Total 229.2 

Calories    940.0 

Entire  number  of  calories  


3.0 
10.0 

8.0 
13.5 


1.7 
1.7 
3.0 


3.6 
13.5 
4.0 
3.5 
1.5 

9.0 


85.1 
790.0 


Carbo- 
hydrates. 

4.8 


1.7 


8.0 
8.0 


3.5 
4.8 
1.7 


66.7 
12.0 


Alco- 
hol. 


8.0 


8.0 


149.4  16.0 
600.0  112.0 
2442 


Einhorti's  Diet  in  H yperchlorhydria. 


Calories. 
160 


7.30  A.  M. :     Two  eggs,  50  gm 

Wheaten  bread,  50  gm 128 

Butter,  20  gm 163 

Milk  250  gm 169 

10.30  A.  M. :     Zoolak  or  milk  200  gm 135 

Crackers  or  bread,  30  gm 77 

Butter,   10  gm 81 

1  P.  M. :     Broiled  meat,  100  gm 210 

Mashed  potatoes,  50  gm 63 

Bread,  30  gm 77 

Butter,   10  gm 81 

Weak  tea  or  Vichy  water,  200  gm. 

3.30  P.  M. :     The  same  as  at  10.30  a.  m 293 

6.30  P.  M. :      Soup  (with  barley  or  vermicelli),  200  gm 100 

Bread  and  butter   (bread,  30  gm. ;  butter,  10  gm.)  158 

Meat   (broiled  or  cooked),  100  gm 210 

Potatoes,  baked,  50  gm 60 

Green  vegetables   (spinach,  green  peas),  50  gm..  .  .  80 

Coffee  (half  milk),  100  gm 34 

10  P.  M. :     Oysters  and  crackers,  or  cold  meat  sandwich,  one 

glass  of  beer  260 

2539 


DIET  IN  INTESTINAL  DISEASES 

The  diet  plays  quite  as  important  a  role  in  the  treatmen.  or  diseases 
of  the  intestine  as  it  does  in  the  treatment  of  gastric  disorders.  In 
many  intestinal  disturbances,  such  as  acute  intestinal  catarrh,  diar- 
rhea, etc.,  cures  can  often  be  effected  by  diet  alone,  when  without  this 
mode  of  treatment  the  disease  might  become  intractable.     The  diet 


474 


DIET  IX  DISEASE 


iu  intestinal  diseases,  as  in  gastric  disorders,  must  be  such  as  will 
produce  no  annoying  symptoms.  The  process  of  digestion  in  the 
intestine  is  exceedingly  complicated,  and  therefore  the  digestibility  of 
foods  in  this  part  of  the  alimentary  tract  is  most  difficult  to  deter- 
mine. This  subject  was  studied  by  Kubner,i  ^j^q  determined  the 
degree  of  absorption  of  various  foods  in  the  intestine.  The  table 
below  gives  his  results. 

It  is  thus  shown  that  certain  forms  of  foods  contain  very  large 
proportions  of  protein  matter,  but  that  their  absorbability  is  so  slight 
that  their  nutritive  value  is  far  lower  than  that  of  foods  containing 
less  protein.  Thus,  while  peas  contain  considerably  more  protein 
(7  per  cent.)  than  does  milk  (3.7  per  cent.),  a  much  smaller  propor- 
tion of  protein  is  absorbed  in  the  case  of  the  former  than  in  that  of 
the  latter;  on  the  other  hand,  the  absorbability  depends  greatly  on 
the  mode  of  preparation  of  the  food ;  when  vegetables  are  mashed  and 
then  strained  so  as  to  rid  them  of  their  cellulose  envelopes,  they  are 
much  more  readily  absorbed  than  when  eaten  with  the  cellulose.     The 

Miibner^s  Diet  in  Inleatinal  Diseases. 


Food-stuflFs. 


Meat 

Eggs 

Milk 

Milk  and  cheese 
White  bread  .  . 
Black  bread  .  . 
Macaroni  .  .  . 
Indian  com  .  . 
Com  and  cheese 

Kice 

Peas 

Potatoes  .... 


Weight  of  same 
in  grams. 


Carrots 


984 

984 

2470 

2490 

860 

1360 

695 

750 


638 

600 

3078 

3830 

2566 


37G 
247 
315 
420 
753 
765 
626 
641 
780 
552 
521 
819 
406 
352 


Absorbed  in  percentages  of— 


.2  03 


95 
95 
92 
94 
95 
85 
96 
93 
96 
96 
91 
91 
85 
79 


97 

94-99 
96 
81 
68 
83 
85 
93 
80 
83 
68 
82 
61 


95 

95 
95-97 


94 
83 
91 
93 

96 
94 
94 


100 
100 
99 
89 
99 
97 
96 
99 
96 
92 
85 
82 


82 
82 
51 
74 
93 
64 
76 
70 
81 
85 
68 
84 
81 
76 


digestibility  of  certain  foods  in  the  intestine  varies  greatly  with  differ- 
ent individuals.  For  this  reason  exact  rules  cannot  be  formulated 
in  any  case,  but  the  diet  must  be  varied  according  to  individual 
peculiarities.  Boas  -  has  expressed  his  opinion  on  this  subject  as  fol- 
lows: 

"1.  In  a  number  of  intestinal  diseases  a  change  of  diet  is  unneces- 
sary or  may  even  be  harmful. 

1  Zeitschr.  f.  Biologic,  vol.  xv.,  p.   115. 
2  Diseases  of  the  Intestine,  p.  141. 


DIET  IN  IXTfJSTIXAL  DItiEASES  475 

"2.  In  some  cases  special  dietetic  restrictions  are  directly  indicated, 
but  these  should  be  as  few  as  possible. 

"3.  In  another  series  of  cases  an  abundant,  heavy,  not  easily  di- 
gestible or  absorbable  diet  is  indicated. 

"4.  The  general  aim  of  our  treatment  should  always  be  to  so  man- 
age the  case  before  us  that  digestion  of  a  normal  diet  will  always 
occur  in  the  alimentary  canal  without  any  subjective  or  objective 
disturbances.  Under  these  circumstances  only  can  the  case  be  con- 
sidered cured." 

According  to  their  effect  on  intestinal  peristalsis,  foods  may  be 
divided  into  three  classes :  those  inducing  constipation ;  those  pro- 
ducing a  laxative  effect,  and  those  exerting  no  especial  effect  in  either 
direction.  In  the  first  class  are  those  foods  containing  an  astringent, 
such  as  tannin;  among  these  may  be  mentioned  certain  red  wines, 
cocoa,  and  tea.  Rice,  tapioca,  barle3%  sago,  macaroni,  and  potatoes 
have  a  tendency  to  produce  constipation  in  many  individuals. 

Among  the  laxative  foods  may  be  mentioned  fruits  and  certain 
vegetables,  as  cucumbers,  tomatoes,  and  cabbage ;  cider,  buttermilk, 
beer,  and  the  carbonated  waters  also  exert  a  laxative  effect. 

In  the  third  class,  foods  that  have  no  especial  effect  on  the  intestinal 
movements,  may  be  placed  meats,  fish,  eggs,  toasted  bread,  and  zwie- 
back. It  must  be  remembered,  however,  that  certain  foods  that  prove 
laxative  in  one  individual  may  be  constipating  in  another,  so  that  no 
precise  rules  can  be  formulated;  in  each  case  individual  tendencies 
must  be  consulted. 

In  severe  forms  of  intestinal  disturbances  rectal  alimentation  must 
often  be  resorted  to.  For  a  further  consideration  of  the  technic  and 
forms  of  food  to  be  utilized  in  this  method  of  feeding  the  reader  is 
referred  to  the  section  on  Rectal  Feeding.  In  those  cases  in  which 
food  cannot  be  given  either  by  the  mouth  or  by  the  rectum  sub- 
cutaneous feeding  becomes  necessary ;  for  this  purpose  olive  oil  may  be 
used ;  one  ounce  may  be  injected  twice  daily  under  the  skin,  best  in 
the  region  of  the  thigh ;  in  some  cases  normal  salt  infusions  are 
indicated. 

In  determining  the  diet  of  patients  affected  with  intestinal  dis- 
turbances it  is  important  to  ascertain  the  physiologic  activity  of  the 
intestines  by  means  of  the  Schmidt  test  diet.  By  means  of  this 
method  of  examination  of  the  feces  one  can  determine  which  food 
constituent  is  badly  digested  and  whether  carbohydrate  fermentation 
or  protein  putrefaction  is  present.  Thus  it  is  possible  to  so  vaiy 
the  diet,  so  as  to  prevent  certain  undesirable  bacterial  flora  from 
multiplying  to  a  great  degree.  Herter  and  Kendall  have  noted  the 
extensive  bacterial  degeneration  following  a  change  from  one  diet  to 
another  and  have  concluded  that  in  conditions  of  disturbances  of  the 
intestinal  tract  when  undesirable  bacteria  propagate  on  both  a  protein 
and  on  a  carbohydrate  diet  frequent  changes  in  the  diet  are  beneficial 


476  DIET  ly  DISEASE 

by  interfering  with  the  too  rapid  growth  of  any  one  type  of  bacteria. 
Recently  Hull  and  Rettger  have  shown  that  milk  owes  its  beneficial 
action  to  the  lactose  present.  When  lactose  is  taken  in  liberal  quan- 
tities together  with  other  food  the  flora  shows  evidence  of  change. 
Milk  and  lactose  together  form  according  to  these  investigators,  the 
most  practical  and  effective  diet  in  reducing  the  putrefying  tj^pes  of 
bacteria. 

Antiputrefactive  Diet. — The  most  important  food  containing  pro- 
tein and  yet  acting  in  an  antiseptic  way  is  milk.  It  has  both  a  high 
nutritive  value,  is  easily  assimilated,  and  yields  a  very  small  amount 
of  products  of  decomposition.  If  it  produces  indigestion,  as  it  does 
in  some  instances,  this  effect  can  be  overcome  by  the  addition  of  rice, 
oatmeal,  milk  of  magnesia,  or  citrate  of  soda. 

When  milk  is  badly  borne,  one  finds  usually  that  it  ferments  too 
rapidly,  and  that  the  intestine  is  stimulated  by  the  products  of  de- 
composition. 

In  most  instances  milk  is  the  most  digestible  food  for  patients 
affected  with  intestinal  disorders.  However,  when  it  is  not  well  borne 
in  some  instances,  it  should  be  given  in  small  quantities  together 
with  other  food  such  as  milk  soups,  mushes,  flour-soups  etc.  Milk, 
however,  should  be  given  with  caution  in  catarrh  of  the  intestines, 
and  in  certain  ulcerations  of  the  large  bowel.  In  some  individuals 
kefir  or  yoghurt  must  be  substituted.  Of  other  preparations  the 
artificial  products  such  as  nutrose  and  plamon  are  to  be  recommended. 
Gelatin  is  another  food  which  is  apt  to  inhibit  the  growth  of  organisms 
of  putrefaction  in  the  intestinal  canal  and  therefore  must  be  con- 
sidered a  valuable  form  of  nourishment. 

As  the  patient  improves,  other  articles  of  diet  may  graduallj^  be 
added,  but  with  great  caution.  Of  these,  the  carbohydrate  foods 
should  be  taken  in  the  form  of  zwieback,  crackers,  wheat  bread, 
(stale).  Butter  may  be  given  in  small  quantities.  Finally  cereals 
may  be  allowed  with  the  addition  of  milk  and  cream.  Sugar  should 
be  taken  in  small  quantities ;  gradually  vegetables  may  be  added,  but 
should  be  mashed  and  strained. 

When  eggs  are  given,  they  should  be  taken  with  caution,  in  as 
much  as  patients  affected  with  intestinal  diseases,  at  times  tolerate 
eggs  badly.  Still  later  on,  small  quantities  of  broiled  minced  meats, 
may  be  added. 

The  coarse  shreds  of  connective  tissue  found  in  meats  should  be 
extracted,  especially  in  cases  of  diarrhea,  due  to  achylia-gastrica,  in- 
asmuch as  these  can  be  digested  neither  in  the  stomach  nor  in  the 
bowel,  and  thus  act  as  an  irritant  to  the  intestine,  and  at  the  same 
time  become  a  nidus  for  the  growth  of  many  putrefactive  organisms. 
Stewed  fruits  are  permissible,  the  skins  and  seeds  being  first  removed. 

Antifermentative  Diet. — By  antifermentative  diet  we  especially 
refer  to  those  forms  of  carbohydrate  food,  which  are  least  apt  to 


DIET  IS  IXTESTINAL  DISEASES  477 

cause  fermentation,  especially  diarrhea.  Fermentation  is  especially 
liable  to  occur  in  both  acute  and  chronic  catarrh  of  the  bowels,  bac- 
teria growing  upon  a  soil  containing  carbohydrates.  These  changes 
are  recognized  by  semifluid,  spongy  conditions  of  the  stools,  which 
are  highly  acid.  In  the  treatment  of  such  cases,  the  quantity  of  car- 
bohydrate food  administered  should  be  reduced  in  quantity  or  this 
article  of  diet  entirely  eliminated,  and  fat  and  proteins  substituted, 
until  the  carbohydrate  fermentation  has  disappeared.  When  there 
is,  in  addition  to  the  carbohydrate  fermentation,  an  acute  or  chronic 
intestinal  catarrh,  the  problem  of  feeding  sometimes  becomes  quite 
difficult. 

The  protein  food  is  apt  to  undergo  putrefaction,  and  the  carbo- 
hydrates fermentation.  At  first  the  diet  should  consist  of  clear 
broths,  with  dry  bread,  or  crackers.  Then  cereals  may  be  added, 
together  wdth  milk.  Finally,  when  this  diet  is  well  borne,  the  more 
solid  foods,  in  the  form  of  chicken,  broiled  meats,  and  butter,  may  be 
allowed.  Milk  should  be  taken  w^ith  caution,  when  fermentation 
exists. 

The  Effect  of  Starvation  on  the  Intestinal  Flora. — According  to 
the  experiments  on  animals,  of  Gushing  and  Livingood  and  more 
recently  of  Sisson  a  relative  amicrobism  is  produced,  after  a  period 
of  24  hours  starvation.  The  greatest  diminution  was  observed  in  the 
duodenum  next  in  the  ileum;  a  large  number  of  organisms,  however, 
were  found  in  the  cecum. 

The  number  of  organisms  is  however,  dependent  on  the  food  residue 
present,  absolutely  sterile  specimens  could  not  be  obtained.  The 
condition  produced  by  starvation,  therefore,  is  according  to  Sisson 
one  of  relative  amicrobism. 

DIET  IN  INTESTINAL  DYSPEPSIA 

In  intestinal  dyspepsia  food  should  be  given  frequently  and  in  very 
small  quantities.  At  first  only  the  liquid  forms  should  be  used,  such 
as  weak  tea,  peptonized  milk,  malted  milk,  bouillon,  and  egg-albumin ; 
after  a  few  days  the  patient  may  gradually  be  placed  on  the  following 
diet:  calves'  brains,  sweetbreads,  broiled  steak  or  lamb  chops,  soft- 
boiled  eggs,  boiled  fish,  such  as  mackerel  or  rock,  baked  potatoes, 
spinach,  asparagus,  and  stewed  fruits. 

The  following  list  gives  the  general  plan  of  a  diet  used  by  the 
authors  in  this  condition. 

Calories. 

8  A.  M. :      150  gm.  milk  with  tea   101 

1  soft-boiled   egg    - 80 

60  gm.  toasted  wheat  bread   (155)  Avith  20  gm.  butter   (IG'.i)  .  .  .  218 

iA   .   ,.        c           ji     t         J    •  ,  1  100  gm.  scraped  beef    (118)"|  „„- 

10  A.M.:     Scraped-beef  sandwich  I  50  gm.  wheat  bread    (178)/ 296 

12  M. :         Bouillon  with  5  gm.  Armour's  Soluble  Beef 10 

100  gm.  broiled  chicken   106 


478 


DIET  ly  DISEASE 


3  P.  M. : 

7    P.  M. ; 


or  100  gm.  broiled  steak    (209).  Calories 

orlUOgm.  lamb  chop    (220). 

50  gm.  mashed  potatoes  or  100  gm.  spinach    (166)    64 

100  gm.   apple-sauce    88 

50  gm.  wheat  bread,  stale  or  as  toast 130 

200  gm.   milk    135 

200  gm.  milk  with  rice   253 

1  soft-boiled   egg    80 

100  em.  wheat  bread  and  50  gm.  butter 666 


Eduards'  Diet  List  for  Intestinal  Dyspepsia. 

Clean  and  disinfect  tlie  mouth  before  eating.  Small  meals 
taken  at  regular  intervals.  Pimctnality  is  of  great  im- 
portance. Masticate  thoroughly;  eat  slowly  and  tem- 
perately. Food  lukewarm  only.  Rest  before  and  after 
meals. 


Soups : 


Fish: 


Meats : 


Eggs: 


Farinaceous    foods: 


Vegetables : 


Dessert : 


Beverages : 


Tlie  patient  may  take: 

Small  quantity.  Clear  soups  of  beef,  mutton,  and  oyster. 
A  little  vermicelli  or  tapioca  may  be  boiled  with  these. 
Cream  pea  soup,  pea  and  tomato  soup,  hominy  and  bean 
soup,  beef-tea  with  yolk  of  egg. 

Oysters  and  little  neck  clams  in  any  form,  except  fried. 
Weaktish,  white  fish,  shad,  cod,  perch,  trout,  bass,  smelt, 
mackerel,  haddock,  corvina,   barracuda. 

Meat-juice,  roast  or  broiled  beef,  mutton,  chicken,  tripe, 
calf's  head,  venison,  tongue,  sweetbread.  No  fatty  meats 
or  sauces. 

Raw,  soft  boiled,  poached,  omelet  combined  with  chicken 
or  oyster.  Eat  dry  toast  or  stale  bread  with  eggs.  May 
combine  eggs  with  wine  or  brandy. 

Bread,  at  least  one  day  old;  brown  bread,  toast,  rye,  glu- 
ten, and  Graham  bread,  zwieback,  crackers,  cream  and 
crackers,  cracked  wlieat,  rice,  sago,  cornmeal,  hominy, 
wheaten  grits,  vermicelli,  rolled  rye,  rice  cakes,  browned 
rice,  baked  flour. 

( Best  made  into  puree  by  paissing  through  a  colander  or 
mashing. )  Greens,  spinach,  lettuce,  watercress,  French 
beans,  green  peas,  asparagus,  celery,  ai'tichokes,  potatoes 
(but  little).  All  vegetables  to  be  used  sparingly  and 
with  caution. 

Rice,  tapioca,  Indian  and  farina  puddings,  custards  (rice, 
snow,  rennet,  sponge  cake,  floating  island),  orange  char- 
lotte, gelatin  creams,  blanc  mange,  baked  and  stewed 
apples  and  pears,  grapes,  and  all  ripe  fruits  (best  stewed, 
but  may  have  to  avoid  fruit  entirely  | . 

(Drinks  should  be  mostly  taken  near  the  end  of  meals). 
Water  one  hour  before  meals,  milk,  lime-water,  weak  tea 
(i  ounce  to  the  pint),  kumiss,  weak  cocoa,  jjeptonized 
cocoa  and  milk.  Mineral  waters  are  not  specially  recom- 
mended. Good  claret  or  Burgundy  diluted  one-half  with 
sterile  water. 


The  patient  must  avoid: 
Rich  soups  and  chowders,  all  fried  foods,  veal,  pork,  liver, 
kidney,  hashes,  stews,  pickled  and  corned  meats,  pre- 
served and  potted  meats,  turkey,  goose,  duck,  sausage, 
salmon,  salt  mackerel,  bluefish,  sturgeon,  eels,  shrimp, 
sardines,  lobster,  crabs,  cabbage,  cauliflower,  cucumbers, 
parsnips,  egg  plant,  turnips,  carrots,  squash,  oyster  plant, 
sweet    potatoes,    beets,   pastry,   pies,   made    dishes,    nuts. 


DIET  IS  ACUTE  INTESTINAL  CATARRH  479 

dates,  jams,  dried  and  candied  fruits,  candies,  cheese, 
whipped  cream,  ice  cream  and  water-ices,  ice-water,  pan- 
cakes, potato  cakes,  pumpernickel,  strong  tea,  malt 
liquors,  sweet  and  etlervescent  wines,  spiriluous  liquors, 
cotfoe. 

DIET  IN  ACUTE  INTESTINAL  CATARRH 

As  in  acute  gastric  catarrh  so  also  in  acute  intestinal  catarrh  the 
regulation  of  the  diet  is  probably  the  most  important  factor  in  the 
treatment  of  the  disease.  The  patient  should  be  kept  in  bed ;  after 
the  bowel  has  been  thoroughly  emptied  by  a  cathartic,  liquid  foods, 
such  as  clear  broths, — at  first  without,  and  then  with  eggs, — thin 
gruels,  light  tea,  cocoa  cooked  in  water,  and  egg-albumin,  should  be 
given  exclusively  for  several  days.  In  this  condition  milk  should  not, 
as  a  rule,  be  given.  When  there  is  extreme  thirst,  the  carbonated 
waters  may  be  allowed,  but  only  in  small  quantities.  The  thirst  is  best 
relieved  by  placing  bits  of  crushed  ice  in  the  patient's  mouth.  After 
the  pain  and  discomfort  have  disappeared,  toast,  crackers,  stewed 
chicken,  soft-boiled  eggs,  mashed  potatoes,  and  boiled  rice  may  be 
added  to  the  diet ;  indigestible  foods,  such  as  raw  fruits,  heavy  vege- 
tables, and  fatty  and  acid  foods  should  be  avoided  for  a  considerable 
period  of  time  after  the  catarrh  has  disappeared. 

DIET  IN  CHRONIC  INTESTINAL  CATARRH 

The  dietetic  treatment  in  chronic  intestinal  catarrh  depends  upon 
the  condition  of  the  fecal  movements;  these  are,  in  a  measure,  an 
index  as  to  the  portion  of  the  bowel  involved.  According  to  Nothna- 
gel,^  cases  of  chronic  intestinal  catarrh  may  be  divided  into  four 
groups : 

"1.  Cases  characterized  by  pronounced  constipation.  An  evacua- 
tion appears  only  once  in  two,  three,  or  four  days;  sometimes  only 
with  the  aid  of  cathartics.  The  fecal  matter  is  usually  hard.  As  a 
cause  of  the  constipation,  Nothnagel  assumes  a  decreased  activity  of 
the  automatic  nervous  apparatus  of  the  intestines,  this  being  the 
result  of  the  catarrhal  process. 

"2.  Cases  in  which  constipation  and  diarrhea  constantly  alternate. 
For  two  or  three  days  there  may  be  a  daily  evacuation  of  very  hard 
dejecta.  On  the  following  day  there  may  be  four  to  six  very  thin  or 
mushy  movements  mixed  with  mucus,  accompanied  by  violent  pains, 
and  then  again  constipation  for  a  day  or  two,  etc.  Or  there  may  be 
((uite  a  normal  evacuation  (once  daily)  for  a  few  days  in  succession 
and  then  again  four  to  seven  diarrheal  movements  in  one  day,  and 
after  this  constipation.  The  principal  feature  of  these  cases  is  the 
constipation,  but  the  excitability  of  the  nervous  apparatus  being  quite 
good,  the  decomposed  stagnant  contents  often  cause  increased  peris- 
talsis  and   diarrhea.     Sometimes   these   alternating   periods   of   con- 

1  Specielle  Pathologie  und  Therap.,  vol.  xvii.,  p.  119. 


480  DIET  IN  DISEASE 

stipation  and  diarrhea  continue  for  a  long  time.  Thus  the  patient 
may  be  constipated  for  four  or  five  weeks,  or  even  for  a  few  months, 
and  then  again  the  diarrhea  may  set  in,  lasting  several  weeks  or 
months. 

"3.  In  a  very  limited  number  of  cases  there  is  a  daily  evacuation, 
which  is  usually  not  formed  or  mushy. 

"4.  Cases  in  which  there  are  for  months  several  diarrheal  evacua- 
tions daily.  The  dejecta,  as  a  rule,  show  the  biliary  reaction,  or  they 
may  contain  yellow  fragments  of  mucus,  yellow-tinged  epithelium,  and 
round-cells.  In  these  cases  the  catarrhal  process  affects  not  only  the 
large  bowel,  but  also  the  small  intestine.  The  absorption  suffers,  and 
there  are  more  abnormal  products  in  the  contents  (acids),  which 
give  rise  to  increased  peristalsis  in  the  small  as  well  as  large  bowel. ' '  ^ 

The  treatment  of  chronic  intestinal  catarrh  therefore  resolves  itself 
into  the  treatment  of  the  accompanying  chronic  constipation,  chronic 
diarrhea,  or  a  condition  of  constipation  alternating  with  diarrhea. 

Diet  in  Chronic  Constipation. — In  this  condition  a  mixed  diet, 
containing,  so  far  as  possible,  those  substances  that  stimulate  the  in- 
testinal peristalsis,  should  be  prescribed.  Astringents  and  anything 
that  tends  to  produce  constipation,  such  as  cocoa,  chocolate,  tea.  red 
wines,  rice,  farina,  etc.,  should  be  avoided. 

The  following  foods  should  be  prescribed  in  cases  of  chronic  con- 
stipation: Graham  and  rye  bread  with  butter,  fruit,  buttermilk, 
kefir,  cider,  beer,  fresh  vegetables,  as  cabbage,  sauer-kraut,  and  salads. 
Fats  are  especially  to  be  recommended,  and  honey  is  also  useful.  Salts 
stimulate  the  intestinal  movements,  therefore  foods  containing  salts 
are  indicated  in  this  condition;  among  this  class  may  be  mentioned 
herring  and  caviare.  Sugar,  especially  milk-sugar,  has  a  marked 
tendency  to  increase  intestinal  peristalsis.  Water  taken  cold  or  on  an 
empt}"  stomach  will  also  stimulate  intestinal  movements. 

Ziveig's  Diet  List  for  Chronic  Intestinal  Catarrh  with  Constipation. 

Early  morning:     Tea  with  milk,  roll,  butter,  honey. 

Morning:     One  glass  of  sour  milk,  buttermilk  or  kefir    (one  day  old). 
Noon:     No  soup. 

Meat  or  fish    (100  gm.). 
Puree  of  vegetables   (liberal  qviantity). 
Dessert   (apple  sauce,  stewed  prunes). 
Rice  or  tapioca  pudding  with  sweetened  fruit  sauce. 
One  glass  of  Sauterne  or  cider. 
Afternoon:     Same  as  early  morning. 
Evening:      One  egg,  cold  or  warm  meat. 
Puree  of  vegetables. 
Dessert. 

Roll,  butter,  soft  cheese  ( camembert ) . 
One  glass  of  cider. 
9  P.  M.:     One  glass  of  ketir   (one  day  old)  or  sour  milk. 

Diet  in  Chronic  Diarrhea. — ^When  severe  symptoms,  such  as  in- 

1  Einhorn,  Diseases  of  Intestines,  p.  100. 


DIET  IX  CHRONIC  INTESTINAL  CATARRH  481 

tense  diarrhea  and  pain,  present  themselves  the  patient  must  be  put 
to  bed  and  kept  on  a  very  rigorous  diet;  the  period  of  rest  may  be 
lengthened  or  shortened  according  to  the  severity  of  the  disease.  In 
moderately  severe  cases  several  weeks  will  usuallj-  suffice.  Nourish- 
ment should  be  taken  in  small  quantities  ever}-  few  hours,  sufficient 
must,  however,  be  given  to  maintain  the  body  weight.  All  cold  drinks 
or  carbonated  waters,  fruits,  cabbage,  and  salads  are  to  be  avoided. 
The  most  suitable  foods  in  this  disorder  are  broths  containing  barley, 
rice,  and  farina,  soft-boiled  eggs,  sweetbreads,  stewed  chicken,  broiled 
steak,  boiled  fish,  toast,  crackers,  baked  potatoes,  tea,  milk  (boiled), 
and  cocoa ;  in  many  cases  port  wine  is  quite  useful,  as  it  contains 
tannin,  which  acts  as  an  astringent 'to  the  bowels.  In  this  condition 
milk  even  when  boiled  is  often  not  well  borne,  and  must  then  be 
avoided. 

The  following  diet-list,  taken  from  Boas,^  illustrates  the  method 
of  prescribing  nourishment  in  chronic  catarrh  of  the  intestine  accom- 
panied by  diarrhea : 

8.  A.M.:     Eichel  cocoa    (in  water),  one  saccharin  tablet   (or  crystallose),  toast 

and  butter   (20  to  30  gm.) . 
10  A.M.:     One   cup    (200   gm.)    rice   gruel,   buckwheat,   or   oaten   grits    in   veal 
bouillon    (avoid  salt).     In  addition:     50  gm.  roasted  veal  or  beef 
( scraped ) ,  fried  fish  or  cold  meat    ( avoid  salt  or  strongly  pickled 
ham ) . 
l.p.  M. :      Soup  of  peas  or  beans  or  puree  of  oatmeal,  farina,  or  cornstarch,  etc. 
(addition  of  nutrose  or  eucasin  allowed;   somatose  forbidden).     In 
summer  huckleberry  soup  ( with  saccharin  if  desired ) . 
200  gm.  of  rice  bouillon  (avoid  rice  with  milk)  or  farina  bouillon,  well 

thickened  by  cooking. 
Green  vegetables  or  potatoes  in  puree  form    ( 50  to   100  gm. ) ,  meat 
and  fish    (fat  excepted)     (50  to   100  gm.)     (butter  sauce  allowed; 
cream  sauces  or  highly  seasoned  sauces  forbidden ) . 
Stewed  fruits,  with   the   exception   of   huckleberries   and   cranberries, 

forbidden. 
Custards    (corn-starch,  with  a   little  yolk  of  egg  and  saccharin)    al- 
lowed.     (Avoid  fruit-juices.) 
As    beverages:     Huckleberry    wine.    Burgundy,    Camarite,    Simaruba 
wine,  old  Bordeaux.      (Sweet  wines,  white  wines,  and  effervescent 
beverages  forbidden.) 
4  P.M.:      Tea    (without  milk)    with   saccharin  or   cocoa,   cakes,  toast,   zwieback 

( with  butter ) . 
7  P.M.:      Strained  gruel    (oatmeal,  etc.),   cold  or  warm  meat    (50  gm.),  toast, 

butter   ( 20  gm. ) . 
9  p.  M. :     One    glass    of    huckleberry    lemonade,    warmed    or    hot    mulled    wine 
( saccharin ) ,  or  tea  without  red  wine. 
Ziveig's  Diet  List  for  Chronic  Intestinal  Catarrh  with  Diarrhea. 
Early  morning:    Acorn    cocoa    cooked    in    milk     (one    saccharin    tablet);    toast, 
butter. 
Morning:    One  to  two  eggs,  toast,  butter. 

Noon:     Soups   (rice,  barley,  oatmeal  witliout  salt). 
Minced  meat  or  fish   (cooked  in  butter). 
Gelatin. 

Rice  or  macaroni. 
One  to  two  glasses  of  red  wine. 
Toast. 

1  Diseases  of  the  Intestines,  p.  224. 
31 


482  DIET  I^  DISEASE 

Afternoon:    Same  as  early  morning. 
Evening :    Soup. 

Fish   (minced). 

Gelatin. 

One  glass  of  red  wine. 

Toast,  butter. 

In  conditions  of  chronic  intestinal  catarrh  in  which  diarrhea 
alternates  with  constipation  the  same  plan  of  treatment  may  be  fol- 
lowed as  has  been  described  for  those  cases  accompanied  by  constipa- 
tion or  diarrhea ;  it  is  especially  important  to  treat  by  diet  the  more 
prominent  symptoms,  whether  it  be  diarrhea  or  constipation.  Mineral 
waters  are  frequently  utilized  in  cases  of  chronic  intestinal  catarrh. 
For  eases  accompanied  by  constipation  the  waters  of  Marienbad  and 
of  Saratoga  (Congress  and  Hathorn  springs)  are  most  beneficial. 
Where  diarrhea  is  the  prominent  symptom,  Carlsbad  and  Vichy  are 
to  be  recommended. 

DIET  IN  DYSENTERY 

The  diet  in  acute  dysentery  is  similar  to  that  prescribed  in  acute 
intestinal  catarrh.  The  patient  is  put  to  bed  and  only  liquid  foods 
are  administered.  Of  these  the  most  suitable  are  bouillon,  broth,  egg- 
albumin,  and  tea;  gradually,  as  the  condition  improves,  semisolids, 
such  as  milk-toast,  rice  cooked  in  milk  or  broth,  gruels  of  tapioca,  etc., 
may  be  prescribed.  Solid  food  should  be  abstained  from  until  a  few 
days  after  the  disorder  has  abated. 

In  chronic  dysentery  the  food  should  be  given  in  small  quantities 
at  frequent  intervals.  All  coarse,  indigestible  food  should  be  avoided. 
In  other  respects  the  diet  is  similar  to  that  already  given  under  Chronic 
Intestinal  Catarrh. 

Ullmann  in  a  recent  study  of  the  sago  like  globules  occurring  in  the 
stools  in  certain  stages  of  dysentery,  calls  attention  to  the  fact  that 
these  granules  are  composed  of  small  masses  of  cellulose  from  the  po- 
tato which  have  not  under-gone  digestion.  Other  materials  may  also 
be  found  acting  as  local  irritants  to  the  intestinal  wall,  continuing  the 
dysenteric  condition.  He  therefore  advises  the  elimination  of  potato 
in  all  forms  and  of  meat  in  any  form  but  scraped.  In  place  of  the 
potato  he  advises  gruels  including  those  made  from  sago  and  rice. 
Wheat  bread  and  zwieback  may  also  be  given. 

Lassablierie  has  tested  the  effect  of  condensed  milk  and  rice  water 
in  the  diarrhea  and  dysentery  of  French  soldiers,  with  exceedingly 
good  effect.  Upon  admission  the  patients  were  at  once  placed  upon 
a  daily  ration  of  one  to  two  liters  of  a  mixture  of  one  part  of  con- 
densed milk  with  four  parts  of  sweetened  rice  water.  Rice  water  is 
easily  digested  and  well  borne ;  while  condensed  milk  is  a  valuable 
food  requiring  but  little  digestive  activity  for  its  proper  assimilation. 
Rice  water  and  condensed  milk  together  combine  many  valuable  prop- 
erties. 


DIET  ly  DYSENTERY  483 

In  the  management  of  the  dj^spepsia  and  malnourishment  associated 
with  chronic  enterocolitis  especially  due  to  infecting  protozoa,  Smith- 
ies advises  the  following  diet. 

7.00  A.M.:      1  pint  of  skimmed  milk  and  2  zwieback. 
9.00  A.  M.:     2  pieces  of  well  cooked  toast  without  butter. 

Juice  of   1    sweet  orange  or   i  grapefruit,   or   ^   of  ripe  melon,   or 
baked  apple  or  dish  of  apple  sauce. 

1  dish  of  well  cooked  cream  of  wheat,  farina  or  oatmeal  with  cream 
and  sugar. 

2  very  soft  poached  eggs  with  butter. 
11.00  A.M.:      1  cup  of  bouillon   (2  cubes)  and  3  crackers. 

1.00  P.  M. :     This  should  be  the  big  meal  of  the  day. 

Meats — rare  if  possible — such  as  beef,  lamb,  well  cooked  or  white 

meat  of  chicken.     Any  kind  of  fresh-water  fish,  but  it  should  never 

be  fried.     Limit  to  4  ounces. 
Vegetables   should    be   cooked   or  well   washed   in   hacteriologically 

clean  loater.     Well  cooked  spinach,  cauliflower,   carrots,   squash, 

peas    (hulled),  string  beans,   Brussels  sprouts,  baked  or  mashed 

potatoes  ( in  moderation ) ,  rice,  with  gravy. 
Simple  puddings  made  from  cereals,  cornstarch,  gelatin,  well  cooked 

fruit  sauces,  simple  cakes. 
Xo  white  breads — all  breads  should  be  made  from  dark  flour  and 

preferably  should  be  at  least  24  hours  old. 
1  pint  of  skimmed  milk  taken  hot. 
4.00  P.  M. :      1  glass  of  hot  malted  milk  or  parboiled  whole  milk  or  cocoa. 

Two  graham  crackers. 
7.00  P.M.:     A  light  supper  consisting  of  vegetable  soup,  toast,   soft  eggs  and 

plain  puddings,  or  sauces  made  from  fruits. 
Simple  cake  may  be  eaten  if  desired. 
1  pint  of  skimmed  milk  and  i  gill  cream  taken  hot. 
Bedtime — 1  glass  of  malt  marrow  or  hot  malted  milk  or  cocoa. 

DIET  IN  ULCERS  OF  THE  INTESTINE 

1.  Diet  in  Ulcer  of  the  Duodenum. — The  diet  in  ulcer  of  the 
duodenum  is  the  same  as  that  of  gastric  ulcer,  and  the  reader  is  re- 
ferred for  the  details  to  the  section  dealing  with  this  subject.  In  cases 
accompanied  by  hemorrhage  absolute  rest  in  bed  must  be  insisted 
upon,  and  rectal  alimentation  administered  if  necessary.  After  the 
first  week  the  Leube  rest  cure  should  be  instituted,  according  to  the 
methods  described  elsewhere.  The  first  form  of  food  to  be  allowed  is 
milk;  after  the  first  week  Carlsbad  water  should  be  given  in  the 
morning.  In  very  severe  cases  Boas  advises  exclusive  rectal  feeding 
for  one  or  two  weeks.  The  authors  have  had  exceedingly  favorable 
results  in  the  treatment  of  many  cases  of  duodenal  ulcer  by  means 
of  the  Lenhartz  and  the  Sippy  cure.     (See  Ulcer  of  the  Stomach.) 

2.  Diet  in  Other  Forms  of  Intestinal  Ulcers. — In  addition  to 
ulcers  occurring  in  the  duodenum,  tuberculous  ulcers,  syphilitic 
ulcers,  toxic  ulcers,  amyloid  ulcers,  and  dysenteric  ulcers  may  occur 
in  the  intestine.  In  any  form  of  ulcer  the  diet  should  be  non-irritat- 
ing and  easily  digestible.  Among  those  foods  that  may  be  given  are 
milk,  eggs,  rice,  farina,  sago,  all  forms  of  broth,  especially  chicken 
and  mutton  broths,  sweetbreads,  stewed  chicken,  baked  potatoes, 
mashed  potatoes,  tea,  cocoa,  crackers,  and  toast. 


484  DIET  IN  DISEASE 

DIET  IN  MALIGNANT  GROWTH  OF  THE  INTESTINE 

The  medical  treatment  in  malignant  growths  of  the  intestine  is 
only  an  adjunct  to  the  surgical  treatment  always  indicated,  and  con- 
sists solely  in  treating  the  symptoms  as  they  arise.  The  diet  should 
be  highly  nutritious  and  at  the  same  time  easily  digestible;  small 
quantities  of  food  should  be  given  at  frequent  intervals.  Milk,  broths, 
soft-boiled  eggs,  raw  scraped  beef,  sweetbreads,  baked  and  mashed 
potatoes,  vegetables,  such  as  carrots  and  peas,  that  have  been  finely 
divided  and  strained,  stewed  fruits,  toast,  and  crackers  are  per- 
missible. 

DIET  IN  ACUTE  INTESTINAL  OBSTRUCTION 

The  treatment  of  acute  intestinal  obstruction,  except  when  due  to 
the  impaction  of  a  foreign  body,  when  it  may  possibly  be  passed 
through  the  bowel,  is  purely  surgical;  as  Treves  has  said:  "There 
is  one  measure  for  acute  intestinal  obstruction,  and  that  is  by  means 
of  laparotomy."  Previous  to  operation  the  following  dietetic  regula- 
tions should  be  carried  out :  The  patient  should  be  kept  in  bed,  and 
in  the  acute  attacks  all  food  should  be  withheld.  Thirst  may  be 
quenched  by  small  bits  of  ice  kept  in  the  mouth  or  a  few  drops  of 
hot  water  may  be  given  at  frequent  intervals.  If  the  disease  extends 
over  a  period  of  several  days,  rectal  alimentation  or  the  administra- 
tion of  salt  solutions  must  be  resorted  to. 

DIET  IN  CHRONIC  INTESTINAL  OBSTRUCTION 

In  this  condition  the  diet  should  chiefly  be  liquid  or  semi-solids. 
All  indigestible  food  should  be  avoided,  especially  those  forms  that 
are  apt  to  leave  a  large  amount  of  residue  in  the  bowel.  The  foods 
to  be  avoided  are  salads,  heavy  vegetables,  and  fruits.  Milk  broths, 
eggs,  broiled  meats,  chicken  and  sweetbreads,  boiled  fish,  rice,  farina, 
toast,  crackers,  and  butter  are  permissible.  In  advanced  cases  rectal 
feeding  must  be  carried  out. 

DIET  IN  APPENDICITIS 

The  dietetic  treatment  in  this  disease  must  be  governed  by  the 
symptoms,  for  surgical  treatment  is  usually  indicated.  The  patient 
should  be  put  to  bed,  and  under  no  condition  be  allowed  to  rise  until 
recovery  is  complete.  During  the  first  days  Sahli  and  Penzoldt 
recommend  that  all  food  be  withheld;  liquids,  such  as  egg-albumin, 
weak  tea,  thin  broth,  barley-  or  rice-water,  or  milk  diluted  with  lime- 
water,  may  be  given  in  small  quantities  when  deemed  necessary. 
When  the  acute  symptoms  have  subsided,  this  diet  can  be  increased 
somew^hat :  the  milk  may  be  taken  undiluted,  and  eggs  may  be  added 
to  the  broth.  When  the  pain  and  fever  have  disappeared  entirely, 
gruels  made  of  rice  or  barley,  soft-boiled  eggs,  scraped  beef,  stewed 
chicken,  toast,  and  crackers  may  be  added  to  the  list ;  still  later  mashed 


DIET  IX  MUC0MEMBRAN0U8  CATARRH  OF  THE  INTESTINE        485 

potatoes  and  vegetables — finely  divided  and  strained — may  be  al- 
lowed, and  finally,  when  the  patient  is  well,  the  usual  diet  may  be 
resumed. 

Ochsner  ^  advises  the  following  plan  of  treatment  in  all  cases  of 
appendicitis  in  which  operation  is  to  be  performed,  believing  that  it 
reduces  the  mortality  and  changes  the  class  of  cases  in  which  the 
mortality  is  greatest  into  another  class  in  which  the  mortality  is  very 
small  after  operation : 

"In  everj^  case  of  acute  appendicitis  all  food  by  mouth  and  all 
cathartics  are  prohibited.  In  case  the  patient  suffers  from  nausea  or 
vomiting,  gastric  lavage  is  at  once  employed.  In  the  milder  cases  the 
patient  is  permitted  to  rinse  the  mouth  with  cold  water  and  to  drink 
small  sips  of  very  hot  water  at  short  intervals.  In  the  severer  cases 
the  patient  is  permitted  to  rinse  the  mouth  with  cold  water,  but  is  not 
permitted  to  drink  either  hot  or  cold  water  for  the  first  few  days 
until  the  acute  attack  has  subsided,  when  the  use  of  small  sips  of  hot 
water  is  begun.  If  the  nausea  persists,  gastric  lavage  is  repeated 
once  or  twice  at  intervals  of  two  to  four  hours,  in  order  to  remove 
any  substance  which  had  regurgitated  into  the  stomach  from  the 
small  intestine." 

"The  patient  is  supported  by  nutrient  enemata  consisting  of  an 
ounce  of  one  of  the  concentrated  predigested  liquid  foods  in  the 
market,  dissolved  in  three  ounces  of  warm  normal  salt  solution  in- 
troduced through  a  catheter  which  is  inserted  a  distance  of  two  and 
one-half  to  three  inches.  In  case  this  gives  rise  to  pain  or  irritation 
or  nausea,  it  is  interrupted  for  twelve  to  twenty-four  hours  at  a  time. 
In  cases  in  which  no  water  is  given  by  mouth  an  enema  of  eight 
ounces  of  normal  salt  solution  is  given  four  to  six  times  a  day  in 
addition  to  the  nutrient  enemata.  In  cases  operated  during  the  acute 
attack  this  treatment  is  continued  for  several  days  after  the  opera- 
tion." 

"After  the  patient  has  been  free  from  pain  and  otherwise  prac- 
tically normal  for  four  days  he  is  first  given  from  one  to  four  ounces 
of  weak  beef-tea,  preferably  prepared  from  commercial  beef  extract, 
every  two  hours.  In  a  few  days  one  of  the  commercial  predigested 
foods,  dissolved  in  water,  is  substituted;  still  later,  equal  parts  of 
milk  and  lime-water ;  then  general  liquids,  then  light  diet ;  and  finally, 
after  the  patient  has  fully  recovered,  full  diet  is  given." 

DIET  IN  MUCOMEMBRANOUS  CATARRH  OF  THE  INTESTINE 

Various  diets  have  been  recommended  in  this  disorder  by  different 
writers.  Fleiner  advises  a  simple  non-irritating  diet ;  others,  as  von 
Noorden,  recommend  a  very  coarse  diet— one  that  will  leave  a  large 
amount  of  residue  in  the  intestine.  The  authors  believe,  with  Ein- 
horn,  that  a  middle  course  is  best,  and  therefore  prescribe  a  nutritious 

1  "The  Mortality  in  Appendicitis,"  Medical  News,  May  2,  1903. 


486  DIET  IN  DIiiEAi:iE 


mixed  diet  that  is  not  too  coarse ;  on  such  a  diet  the  movements  of  the 
bowels  become  more  nearly-  normal  and  the  secretion  of  mucus  is 
lessened.  Von  Noorden  recommends  a  diet  consisting  "largely  of 
Graham  bread — 250  grams  a  day  in  addition  to  a  great  variety  of 
leguminous  vegetables,  including  the  husks ; '  vegetables  containing 
much  cellulose ;  fruit  with  small  seeds  and  thick  skins,  like  currants, 
goose-berries,  grapes,  besides  large  quantities  of  fat,  in  particular 
of  butter  and  bacon.  The  permanent  effect  of  the  diet  is  chiefly  due 
to  the  amount  of  cellulose  which  it  contains.  This  cellulose  undergoes 
decomposition  in  the  intestines  and  thus  softens  the  movements." 
Of  fifteen  patients  •  who  were  treated  by  von  Noorden  in  this  way, 
seven  were  cured  and  seven  improved.  In  conjunction  with  this  diet 
mineral  waters  are  used ;  of  these,  waters  containing  sodium  chlorid 
are  especially  to  be  recommended,  in  particular  those  of  Kissingen  and 
of  Wiesbaden,  (For  a  discussion  of  the  treatment  of  mucomembran- 
ous  catarrh  other  than  by  the  diet — e.  g.,  by  oil  enemata,  irrigations 
of  the  bowels,  etc. — the  student  is  referred  to  the  text-books  on  in- 
testinal diseases.) 

Ewald  ^  advises  the  following  diet  in  certain  cases  of  membranous 
colitis : 

"It  is  only  rational  that  in  these  cases  a  mild,  nourishing  diet 
should  be  instituted,  which  through  its  nourishing  qualities  produces 
a  laxative  effect.  This  diet  maj^  be  followed  whenever  constipation 
does  not  exist — a  so-called  lactovegetable  or  even  constipating  diet. 
The  following  diet  scheme  recommends  itself  for  this  purpose :  Break- 
fast: Sweet  milk,  cocoa,  oatmeal  with  cocoa,  white  or  dark  bread, 
with  honey,  jam,  or  fresh  fruit.  Dinner  (preferably  at  midday)  : 
Vegetables  or  fruit,  as  apples,  plums,  blueberries,  raspberries,  cherries, 
a  broth  of  vegetable  soup,  spinach,  tomato,  or  beet  soup,  a  milk  soup, 
or  curded  milk,  butter,  and  a  liberal  amount  of  fresh  vegetables  are 
desirable,  or  pea,  rice,  or  lentil  soup,  stewed  vegetables  with  dumpling, 
macaroni,  puddings,  blanc-mange  with  fruit-juices,  etc. ;  salads,  and 
eggs  variously  prepared,  bread  with  butter,  and  a  light  cheese.  Sup- 
per: A  thick  soup,  made  with  barley,  rice,  tapioca,  etc.,  baked  po- 
tatoes, eggs,  bread,  butter,  cheese,  milk,  etc. 

"According  to  the  needs  of  the  patient  the  foregoing  diet  will  be 
more  or  less  carefully  followed,  and  on  certain  days  a  small  amount  of 
meat  may  be  allowed  by  way  of  variety. 

"While  this  diet  is  directed  especially  against  the  local  intestinal 
condition,  still  it  serves  well  to  support  and  improve  the  general 
nutrition,  because  of  the  high  percentage  of  carbohydrates  and  fats, 
which  is  very  important." 

Zioeig's  Diet  List  for  Mucomemhranous  CoUtis. 

Early  morning:     Tea  with  milk,  Graham  bread,  butter,  honey. 
Morning:  Glass  of  kefir   (1  day  old),  rye  bread,  butter. 

1  American  Medicine,  1004.  vol.  vii.,  p.  261. 


NERVOUS  AFFECTIONS  OF  THE  INTESTINE  487 

Noon:  No  soup,  meat  or  fish,  vegetables,  salad  with  egg  and  oil,  des- 

sert (fruits),  grapes,  dates,  figs,  oranges,  Graham  bread,  1 
glass  of  eider. 

Afternoon:  Vigor  chocolate,  Graham  bread,  butter,  marmalade. 

Evening:  Egg   or    egg   and    ham,    meat    (cold   or    warm),    salad,    dessert 

(fruit),  Graham  bread,  butter,  cheese,  1  glass  of  cider  or 
white  wine. 

10  P.M.:  1  glass  of  kefir   (1  day  old). 

DIETETIC  TREATMENT  OF  NERVOUS  AFFECTIONS  OF  THE  INTESTINE 

1.  Atony  of  the  Large  Intestine. — The  dietetic  treatment  of  this 
disorder  is  identical  to  that  indicated  for  habitual  constipation,  to  be 
described  further  on. 

2.  Flatulence  or  Meteorism. — This  condition  is  characterized  by 
an  excessive  accumulation  of  gas  in  the  intestine.  In  the  dietetic 
treatment,  therefore,  foods  that  tend  to  produce  large  quantities  of 
gas,  such  as  beer,  cider,  carbonated  waters,  fruit,  cabbage,  rye  and 
Graham  breads,  and  potatoes,  should  be  avoided.  The  disorder  is 
often  of  purely  nervous  origin,  and  when  this  is  the  case,  unrestricted 
diet  is  to  be  recommended — one  that  will  tone  up  the  patient's  system 
and  thus  cause  the  flatulence  to  disappear. 

3.  Diet  in  Intestinal  Neurasthenia. — This  disease  resembles  nerv- 
ous dyspepsia.  At  times  the  most  indigestible  food  is  well  borne, 
whereas  the  digestible  forms  create  discomfort;  in  each  case  it  is 
important  that  the  diet  be  regulated  according  to  the  patient's  diges- 
tive powers.  Generally  a  liberal  diet  is  indicated  in  these  cases; 
in  many  instances  a  systematic  rest  cure  is  needed  to  bring  about 
relief. 

DIETETIC  TREATMENT  FOR  HEMORRHOIDS 

Since  constipation  is  often  a  frequent  cause  and  accompaniment  of 
hemorrhoids  it  is  important  that  this  condition  be  corrected.  As  has 
been  pointed  out  elsewhere,  proper  diet  plays  an  important  role  m 
the  prevention  of  chronic  constipation.  Patients  afflicted  with  hemor- 
rhoids should  eat  in  moderation,  but  should  avoid  all  excesses  of 
food  and  drink.  An  abundance  of  outdoor  exercise,  consisting  of 
walking  and  simple  gymnastics,  should  be  indulged  in,  violent  gym- 
nastics and  horseback-riding  should  be  avoided.  A  daily  evacuation 
of  the  bowels  should  be  secured.  Patients  with  hemorrhoids,  should 
avoid  alcoholic  beverages,  spiced  foods,  strong  coffee  and  tea,  cheese, 
cabbage,  and  beans.  The  foods  most  suited  to  this  condition  are 
potatoes,  carrots,  spinach,  asparagus,  and  even  salads,  since  they 
stimulate  intestinal  peristalsis  and  thus  help  to  keep  the  stools  soft. 
Stewed  and  raw  fruits,  including  grapes,  oranges,  pears,  and  apples, 
are  also  beneficial.  Water  is  the  best  beverage  in  this  condition. 
The  waters  of  Carlsbad,  Kissingen,  and  Saratoga  are  most  beneficial; 
they  act  best  when  taken  at  the  springs. 


488  DIET  IN  DISEASE 

Diet  for  Plethoric  Patients  with   Hemorrhoids. —  {After  Wegele.) 

Morning:       Milk  or  weak  tea,  Graham  bread  and  butter  with  honey. 

Forenoon :      Buttermilk. 

Noon :  Soup,  vegetables,  compote   ( salad ) ,  and  lean  meat. 

Afternoon:    Buttermilk  or  fruit  and  Graham  bread. 

Evening:       Soup,  compote,  cider. 

Mineral  waters  and  grape-juice  may  be  taken. 
Diet  for  Nervous  and  Thin  Patients  with  Hemorrhoids. —  (After  Wegele.) 
Morning:       Milk  witli  tea,  butter,  and  milk. 
Forenoon:      Buttermilk  or  kefir  a  day  old. 
Noon:  Soup,  roast  meat,  light  vegetables,  compote. 

Afternoon:     Kefir  or  tea  and  bread. 
Evening:       Rice  and  milk,  compote,  and  light  white  wine. 

DIET  IN  CHRONIC  DIARRHEA 

The  Authors'  Diet-list  for  Moderate  Cases  of  Chronic  Diarrhea. 

Calories. 

8  A.  M. :     200  gm.  of  cocoa   ( cooked  in  water)    45.0 

2  soft-boiled  eggs   160.0 

50  gm.   toast    130.0 

10  A.  M. :     250  gm.  broth  with  1  egg 80.0 

30  gm.   Panopepton    57.5 

12  M. :         200  gm.  broiled  chicken   212.0 

50  gm.  toast    130.0 

200  gm.  mashed  potatoes   245.0 

4  P.  M. :       50  gm.   Panopepton    57.5 

1  soft-boiled  egg   80.0 

200 gm.  cocoa   (cooked  in  water)    45.0 

50  gm.   toast    130.0 

7  P.  M. :      100  gm.  rice  cooked  in  bouillon  34.0 

200  gm.  sweetbread    180.0 

50  gm.  wheat  bread   130.0 

9  P.  M. :      100  gm.  raw  scraped  beef   118.0 

50  gm.   Panopepton    57.5 

50  gm.  toast    130.0 

2021.5 
Cohnheim's  Diarrhea  Diet  List  is  as  follows: 

7  A.  H. :  Mineral  water ;   hot,  and  taken  in  small  doses  of  75  to  150  c.c. 

The  choice  of  the  water  depends  upon  the  state  of  gastric  secre- 
tions. 

7.30  A.  M.:  Eicliel  cocoa    (2  teaspoonsful  to  a  cup)    in  water,  and  toasted 

white  bread  and  butter. 
10  A.M. :  A  cereal  soup  with  butter,  toast  with  butter,  eggs,  and  scraped 

ham. 

1  P.  M, :  Broth  with  grits,  noodles,  macaroni,  and  white  meat ;   in  mild 

cases,  vegetable  purees,  and  1  glass  of  blueberry  wine. 

4  P.M.:  Same  as  7.30  a.m. 

6  P.  M. :  Mineral  water. 

7  to  8  P.  M. :       Tea  with  red  wine  or  blueberry  wine,   toast,   butter,  and  cold 

white  meat. 
9  to  10  P.  M. :     A  cup  of  hot  peppermint  tea. 

In  mild  cases,  when  the  stool  is  of  a  pulpy  consistency — or 
after  improvement  in  severe  cases — white  bread,  carrots,  fillet, 
and  baked  fish  may  be  allowed. 
Strictly  forbidden: 
Cold  drinks;  any  kind  of  coarse  vegetables,  like  cabbage  or  po- 
tatoes; cheese,  acids,  cakes,  coffee,  all  legumes  (except  when 
served  in  soups)  ;  goose,  duck,  salmon,  animal  fats,  gravies, 
and  raw  fruits. 


yERYOUS  AFFECTIOyS  OF  THE  lyTESTINE 


489 


The  dietetic  treatment  of  diarrhea  must  vary  according  to  the  type 
of  the  disorder.  In  the  nervous  variety  the  patient  should  be  in- 
structed to  restrain  his  bowel  movements  except  at  a  certain  hour  in 
the  morning.  Under  all  conditions  it  is  important  to  exclude  from 
the  diet  all  foods  that  have  a  tendency  to  stimulate  the  intestines. 
Coarse,  indigestible  foods,  especially  those  containing  a  large  percent- 
age of  cellulose,  must  be  avoided;  in  this  class  are  especially  to  be 
mentioned  cabbage,  pickles,  salads,  turnips,  carrots,  all  cold  drinks, 
carbonated  waters,  and  beverages  (including  champagne  and  beer). 
Among  the  foods  to  be  recommended  are  broths,  tea,  red  wines,  farina, 
rice,  and  barley  gruels.  Raw  milk  usually  has  a  laxative  effect,  but 
when  boiled  or  diluted  with  lime-water  or  brandy  it  is  constipating, 
although  in  a  certain  number  of  cases  it  must  be  entirely  excluded 
as  it  increases  the  number  of  movements.  In  a  number  of  cases  of 
chronic  diarrhea  milk  cures  have  been  given  with  good  results.  The 
authors  have  succeeded  in  relieving  cases  of  chronic  diarrhea  by 
systematic  rest  cures. 

Diet-list  for  Chronic  Diarrhea   (Severe  Cases). —  (After  Wegele.) 

■D     I  ■  171  *  Carbo-       Alco- 

Protein.      Fat.       hydrates.      hoi. 

Morning:         200  gm.  acorn  cocoa  (boiled  in  water)  2.3  3.60         12.0 

1  soft-boiled   egg    6.0  5.00 

Forenoon :        250  gm.    decoction    of    whortleberries 

from  80  gm.  dried  berries  ....  0.6  1.30           4.7 

Noon :                250  gm.  soup 5.5  4.00           7.5 

1  egg  in  the  soup   6.0  5.00 

100  gm.  scraped  meat    (lean)    20.7  1.50 

50  gm.  rice  in  bouillon 4.0  0.50         38.0 

Afternoon:       250  gm.  whortleberry  decoction 0.6  1.30           4.7 

Evening:           250  gm.  maltoleguminose  soup   6.5  0.25         15.5 

with  1  egg 6.0  5.00 

150  gm.  minced  chicken   15.0  9.00         12.0 

^'div"  *^'^    }  '  ^  ^-  ^^ieback   9.0         1.50         42.5 

200  gm.  whortleberry  wine ...  7.0         17.0 

10  o'clock       loSOgm.  barley  mush  (20:250)    5.0         4.00         25.0 

at  night :    J 

Total 87.2       42.00       16.89         17.0 

Calories    360  390  690  120 

Entire  number  of  calories 1560 

Diet-list  for  Chronic  Diarrhea   (Less  Severe  Cases). —  (After  Wegele.) 

■D t-,„  -cint  Carbo-         Alco- 

Protein.         Fat.         hydrates.        hoi. 

Morning:       200  gm.  acorn  cocoa  2.30  3.6  12.00 

1  egg    6.00  5.0 

Forenoon:      240  ^.  kefir    (four  days  old)    8.20  5.7  2.00           3.3 

Noon :             250  gm.  soup    5.50  4.0  7.50 

1  egg    6.00  5.0 

150  gm.  roasted  chicken   28.00  10.0  1.80 

250  gm.  mashed  potatoes 6.00  1.7  42.70 

2  o'clock:      250  gm.  acorn  cocoa  2.30  3.6  12.00 

6  o'clock:      250  gm.  kefir    8.20  5.7  2.00           3.2 


490  DIET  IN  DISEASE 

Prntpiti  Fat  Carbo-         Alco 

i-rotein.         iat.       hydrates.       hoi. 

8  o'clock:      200  gm.  soup    3.30  6.0  17.00 

1  egg    6.00  5.0 

100  gm.  sweetbread 28.00  0.5 

10  o'clock:    250  gm.  kefir    8.20  5.7           2.00           3.3 

During  the      75  gm.  zwieback  or  toasted  bread. .  .  9.00  1.5  42.50 

day:              20 gm.  butter 0.15  16.6           0.12 

250  gin.  whortleberry  wine ...  ...            8.75         21.5 

Total   .127.00         79.6       150.25         31.3 

Calories 520  740  615  210 

Entire  number  of  calories 2085 

DIET  TREATMENT  IN  HABITUAL  CONSTIPATION 

Aside  from  the  general  causes  of  chronic  constipation,  such  as 
hereditary  tendencies,  irregular  habits,  sedentary  occupations,  dietetic 
irregularities,  and  constitutional  diseases,  there  are  certain  local  causes 
of  chronic  constipation  which  must  be  borne  in  mind.  There  are 
those  forms  due  to  retarded  intestinal  peristalsis  (atony  of  the  in- 
testines) and  those  due  to  spasmodic  contractions  of  a  portion  of  the 
intestine;  we,  therefore,  recognize  an  atonic  constipation  and  a 
spasmodic  constipation.  Both  conditions  may  exist  in  the  same  in- 
dividual. 

In  the  dietetic  treatment  of  habitual  constipation  it  is  essential  that 
the  food  that  is  ingested  should  be  such  as  will  increase  the  intestinal 
movements.  Those  foods  that  leave  a  large  bulk  of  fecal  matter  are 
useful  for  this  purpose.  Those  that  leave  a  small  residue  are  most 
apt  to  produce  chronic  constipation.  A  diet  consisting  principally 
of  eggs  and  milk  with  only  a  small  quantity  of  vegetables  and  water 
is  one  that  is  constipating, 

A  glass  of  cold  water  taken  before  breakfast  will  often  regulate 
the  bowels;  occasionally,  according  to  Penzoldt,  a  pinch  of  salt  added 
to  the  water  will  increase  its  efficacy ;  raw  or  cooked  fruit,  taken  on  an 
empty  stomach  morning  or  evening,  occasionally  gives  good  results. 
It  is  a  well-known  fact  that  the  smoking  of  a  cigar  in  the  morning 
will  often  stimulate  peristalsis.  The  patient  should  recognize  the 
importance  of  having  an  evacuation  of  the  bowels  at  the  same  time 
each  day. 

Chronic  constipation  is  a  frequent  accompaniment  of  dyspeptic 
disorders,  and  may  be  relieved  by  appropriate  treatment  of  the  gastric 
disorder.  It  should  not  be  forgotten  that  habitual  constipation  is 
frequently  induced  by  the  persistent  use  of  cathartics,  and  the  use  of 
drugs  should  be  avoided  as  much  as  possible  in  the  treatment  of  this 
disorder.  Sedentary  habits  are  often  the  cause  of  constipation,  and 
for  this  reason  proper  exercise  should  always  be  prescribed  along 
with  the  dietetic  treatment.  The  vegetables  that  are  especiallj^  use- 
ful in  the  treatment  of  chronic  constipation  are  lettuce,  squash,  car- 


DIET  TREATMENT  IN  HABITUAL  CONSTIPATION  491 

rots,  oyster  plant,  turnips,  spinach,  peas,  cauliflower,  cabbage,  aspara- 
gus, salads,  onions,  celer}-,  and  tomatoes  which  contain  considerable 
cellulose  and  thus  leave  a  large  residue  in  the  intestine.  Potatoes 
are  best  taken  baked  and  eaten  with  the  skins.  The  cereals  that 
stimulate  the  intestinal  movements  are  oatmeal  and  cornmeal. 
Graham,  rye,  corn,  whole  wheat,  and  bran  breads  are  also  useful. 
Other  foods  classed  as  laxatives  are  honey,  cider,  molasses,  and  acid 
fruits,  such  as  apples,  pears,  peaches,  cherries,  and  oranges.  On  ac- 
count of  the  acids  and  seeds  they  contain,  berries  are  effective  laxa- 
tives. Prunes,  dates,  and  figs  are  also  to  be  recommended.  Fats  are 
to  be  given  freely,  best  in  the  form  of  butter,  cream  and  olive  oil. 
In  some  instances  olive  oil  enemata  retained  over  night  are  of  the 
greatest  help  in  the  relief  of  this  condition. 

Diet-list  for  Chronic  Constipation. —  (After   Wegele.) 

Protein.         Fat.       ^^Carb.  Alco- 

Morning:                     200  o;m.  milk  and  coffee 3.20  4.40  3.20 

30  gm.  butter 0.21  24.50  0.1.5 

30  gm.  honev 0.35  0.03  17.00 

Forenoon:                    300  sm.   buttermilk    12.15  2.80  11.20 

iS'oon:                           200  gm.  bouillon    1.00  0.60  1.20 

200  gm.  mutton 23.20  50.50  0.70 

300  gm.  curh^  cabbage 4.20  14.40  21.60 

200  gm.  plums 0.80  ...  11.60 

300  gm.  white  wine  or  cider.  ...  ...  9.00         24.7 

Afternoon:                   300  gm.  buttermilk 12.15  2.80  11.20 

Evening:                      150  gm.  meat 28.20  11.00  0.10 

30  gm.  butter 0.21  24.50  0.15 

300  gm.   stewed  apples    1.00  ...  39.00 

250  gm.  Graham  bread    ....  22.50  2.50  125.00 

After  evening  meal:  750  gm.   beer    42.60  6.50  4.70         28.8 

Total     145.77       194.50       245.80         53.5 

Calories     600  1800  1000  375 

Entire  number  of  calories   3775 

Habitual  constipation  is  often  due  to  the  fact  that  water  is  taken  in 
insufficient  quantities;  therefore,  in  the  treatment  of  the  disorder,  an 
abundance  of  water  must  be  prescribed.  The  foods  to  be  avoided 
are  tea,  claret,  cocoa,  chocolate,  rice,  barley,  and  farina  gruels,  and 
huckleberries.  In  some  cases  milk  acts  as  a  laxative,  whereas  in 
others  it  has  the  opposite  effect.  For  this  reason  its  effect  should  be 
tested  in  every  case.  Boiled  milk  usually  constipates.  Buttermilk 
is  preferable  to  sweet  milk  as  a  laxative.  Most  cases  of  habitual  con- 
stipation can  be  relieved  or  cured  by  the  dietetic  treatment  here  laid 
down;  it  is  not  within  the  province  of  this  book  to  discuss  the  value 
of  massage  and  electricity;  suffice  it  to  say  that  they  are  reliable  ad- 
juvants to  the  treatment  of  constipation. 


492 


DIET  IN  DISEASE 


"Carbo-hydrate-Cellulose"  Foods —  ( Krause-Garre) . 

100  Grams.  Water.  Proteid.  Fat.  hydrates      Cellulose.  Calories. 

Cauliflower     90.89  2.5  .3  4.5  9.91  30 

Spinach    88.5  2.49  .58  4.4  .93  33 

Tomatoes    94.3  .9  .4  3.9  1.1  23 

Celery   94.5  1.1  .1  3.3  .9  19 

Potatoes    (raw)    78.3  2.2  .1  18.4  1.  85 

Peas    (green)     9.5  24.6  1.  62.  .5  365 

Beans    (butter)     58.9  9.4  .6  29.1  4.  163 

Turnips     89.6  1.3  .2  8.1  8.4  41 

Parsnips     83.  1.6  .5  13.5  1.6  66 

Cabbage    91.5  1.6  .3  5.6  2.  32 

Apples    (dried)     27.9  1.2  3.6  59.7  5.  250 

Pears    (dried)     29.4  2.07  .8  58.8  6.9  260 

Prunes    (dried)     29.3  2.25  2.75  62.  1.5  265 

Grapes    78.2  •     .6  .8  16.3  3.6  70 

Strawberries      87.6  1.07  .93  6.76  2.32  30 

Figs     18.8  4.3  .3  74.2  7.3  325 

Dates     15.4  2.1  2.8  78.4  5.5  356 

Honey     19.61  1.2  .02  73.72  300 

Cane  Sugar   2.16  .35  96.23  400 

Sago    12.8  .8  86.1  355 

Tapioca     13.3  .6  85.  350 

Macaroni    13.07  9.2  .3  76.8  350 

Walnuts      4.7  16.4  62.9  7.9  6.2  685 

Almonds     5.4  24.2  53.7  7.2  6.6  629 

Oatmeal    (Scotch)    12.37  10.41  5.23  57.8  11.2  300 

Corn  Meal   14.32  .4  85.  350 

Zwieback    1.18  13.3  3.18  82.  .5  460 

Rye  Bread   42.2  6.1  .4  47.36  1.5  210 

Graham   Bread     34.  9.  1.  50.  4.  250 

Potatoes  are  best  taken  baked  and  eaten  with  the  skins. 


The   authors  frequently  prescribe  the  following  diet  in  cases  of 
chronic  constipation : 

Calories. 

6  A.M.:       40  gm.   orange-juice    88 

8  A.  M. :      300  gm.  milk  with  coffee   192 

2  soft-boiled   eggs    160 

150  gm.  Graham  bread  375 

40  gm.  butter    326 

10  A.  M. :     400  gm.  cider   280 

12  M. :  200  gm.  broth,  witli  1  egg 84 

100  gm.  steak   214 

100  gm.  carrots  41 

100  gm.  beans  193 

150  gm.  Graham  bread 375 

200  gm.  stewed  apples   106 

4  P.  M. :     400  gm.  buttermilk   166 

7  P.  M. :      100  gm.  scraped  beef    118 

150  gm.  Graham  bread 375 

200  gm.  stewed  prunes  176 

300  gm.  cider    210 

9  P.  M.:       40  gm.  figs   (or  400  gm.  buttermilk)    46 

3525 

Sutherland's  Diet  List  for  Chronic  Constipation. 

Half  an   hour   before  breakfast,    10   fluidounces   of  hot   water 

with  a  small  dose  of  Carlsbad  salt  dissolved  in  it,  insuflScient 


DIET  TREATMENT  IX  HABITUAL  COXSTIPATION 


493 


Breakfast ; 


Lunch : 


5  P.M.: 


Dinner : 

Bedtime : 

7 

A.  M. : 

1  ■ 

30  A.  M. : 

10 

A.  M.: 

12 

M.   to    1    P.  M, 

4 

p.  AI. : 

7 

P.  M. : 

9 

to   10  p. 

M. : 

7 

A.  M. : 

7. 

30  A.  M. : 

10 

A.  M. : 

12 

to    1    p. 

M.: 

4 

p.  M. : 

6 

p.  M. : 

7 

to   8   P.  M. : 

9 

to    10  P. 

M. ; 

to  produce  an  obvious  aperient  effect;  or  the  juice  of  an 
orange  made  up  to  10  ounces  with  cold  water. 

CotFee  with  milk  and  sugar,  10  ounces  Ciraliam  or  whole  meal 
bread  or  toast,  3  ounces  porridge  with  milk  or  cream  (2 
ounces  of  [Scotch  oatmeal),  1  egg  (or  fish  or  fat  bacon); 
butter,  1  ounce;  honey,  i  ounce  (or  treacle  or  home-made 
marmalade),  2  apples,  baked  or  raw  (or  bananas,  pears,  or 
other  fruit  in  season). 

Bread  or  toast  as  above,  3  ounces  (or  whole  meal  biscuits)  ; 
fish,  2  ounces  (or  chicken  or  meat)  ;  French  beans,  4  ounces 
(or  onion,  celery,  cabbage,  or  Brussels  sprouts)  ;  salads  with 
oil,  2  ounces  (lettuce,  potato,  beet);  stewed  fruit,  with 
cream,  2  ounces  (prunes,  apple  charlotte,  or  puree)  ;  butter, 
i  ounce;  lager  beer,  10  ounces  (or  cider.  Hock,  Moselle, 
Berncastler ) . 

Coffee,  milk,  and  sugar,  8  ounces;  bread,  toast,  or  whole  meal 
biscuits,  as  above,  2  ounces. 

Clear  soup,  6  ounces;  otherwise  as  at  lunch. 

Water,  plain  or  aerated,  10  ounces;  whole  meal  biscuits. 

A.  Cohnheim's  Diet  in  Atonic  Constipation. 
One  glass  of  cold  water. 

Malt  coffee  or  tea  with  milk,  1  teaspoonful  of  milk-sugar, 
whole  wheat  bread  with  butter,  honey,  or  marmalade. 

Buttermilk  two  days'  old.  kefir,  kumiss,  or  sour  milk,  whole 
wheat  bread,  butter,  and  ham. 

Vegetables,  including  cabbage,  small  amounts  of  meat,  an 
abundance  of  sweet  fruit  juices,  and  1  glass  of  cider  sweet- 
ened with  1  tablespoonful  of  milk-sugar. 

^lalt  coffee  or  tea  with  milk,  whole  wheat  bread  and  butter. 

J  liter  of  two  days'  old  kefir  or  kumiss,  Pilsener  beer,  bread 
and  butter,  eggs,  or  cold  sliced  meat. 

Fruit  or  honey  cakes. 

Strictly  Forbidden: 

Rice,  gruel,  sago,  and  cereal  soups. 

B.  Conheim's  Diet  in  Spastic  Constipation. 
One  glass  of  hot  peppermint  and  valerian  tea. 

Tea  with  cream  and  a   tablespoonful   of  milk-sugar,  and   fine 

white  bread  with  butter  and  raspberry  jelly. 
Kumiss  or  kefir  two  days'  old,  white  bread  and  butter,  and  1 

egg- 
One  small  plate  of  soup,  tender  vegetables  cooked  in  butter. 

meat,  stewed  fruits,  and  1  glass  of  raspberry  lemonade. 
Same  as  7.30  a.  m. 
\  liter  of  kefir  or  kumiss. 
Tea  with  cream,   1   tablespoonful   of  milk-sugar,  white  bread, 

butter,  and  cold  meat. 
Puree  of  fruit. 

Forbidden : 
Cabbage,  coarse  bread,  goose,  duck,  and  all  raw  fruits,  except 

sweet  apples,  oranges,  and  grapes. 


DIET  IN  CHRONIC  INTESTINAL  STASIS 

Intestinal  stasis  is  a  condition  often  associated  with  chronic  con- 
stipation. According  to  Lane  the  main  factors  in  the  production  of 
this  condition  are  certain  bands  and  membranes  developing  on  the 
peritoneum  from  the  large  and  small  bowel,  producing  kinks  and 
the  resulting  stasis.  Lane  defines  chronic  intestinal  stasis  as  "a 
delay  in  the  passage  of  the  contents  of  the  intestinal  canal  of  sufficient 
length  as  to  result  in  the  production  of  an  excess  of  toxic  material, 


494  DIET  IN  DISEASE 

and  in  the  absorption  of  a  greater  quantity  of  poisonous  products 
than  the  organs  which  convert  and  excrete  them  are  able  to  deal 
with."  He  refers  to  the  symptoms  as  "auto-intoxication  of  chronic 
intestinal  stasis"  and  believes  that  this  toxemia  is  responsible  for 
many  general  and  nervous  symptoms.  In  many  of  these  cases  there 
is  a  marked  enteroptosis.  The  treatment  of  chronic  intestinal  stasis 
is  largely  that  of  chronic  constipation,  together  with  the  treatment 
of  the  accompanying  nervous  symptoms.  Einhom  calls  attention  to 
the  fact  that  patients  should  be  impressed  that  no  harm  can  ensue 
even  if  the  bowels  do  not  move  for  several  days  at  a  time,  and  should 
be  instructed  to  go  to  stool  at  the  same  hour  each  day,  and  not  pay 
further  attention  to  the  bowel  movements  until  the  following  day. 

The  diet  to  be  prescribed  in  this  condition  is  practically  that  which 
has  already  been  described  under  the  head  of  chronic  constipation. 
Water  should  be  taken  liberally  and  vegetables,  fruits,  and  salads  given 
plentifully.  Paraffine  oil  is  most  helpful  in  many  cases  and  agar- 
agar  often  assists  greatly  in  relieving  the  constipation.  Olive  oil  by 
mouth  or  by  enema  to  be  retained  over  night  is  often  of  the  greatest 
benefit.  In  many  instances  an  initial  radical  change  should  be  made 
in  the  diet  in  an  attempt  to  change  the  bacterial  flora.  Physical 
measures  including  massage,  electricity  and  the  wearing  of  an  ab- 
dominal support  are  to  be  recommended  in  some  cases.  In  a  small 
proportion  of  cases  operation  is  indicated. 

The  diet  should  be  of  such  a  character  as  to  leave  considerable 
residue.  The  breakfast  should  consist  of  eggs,  a  cereal,  oatmeal,  corn- 
meal  bread,  graham  bread,  bran  bread  or  whole  wheat  bread,  together 
with  fruit.  The  noon  meals  should  especially  contain  such  vegetables 
as  cabbage,  peas,  beans  or  cauliflower  with  graham  or  branbread,  and 
the  evening  meal  should  consist  largely  of  similar  course  vegetables, 
together  with  meat,  graham  bread,  and  a  salad  and  stewed  fruit. 
If  the  patient  is  undernourished,  a  rest  cure  with  massage  and  forced 
feeding  will  often  produce  splendid  results.  If  the  patient  is  over- 
nourished  a  reduction  cure  is  to  be  recommended.  In  many  instances 
buttermilk,  or  other  forms  of  fermented  milk  are  valuable  additions 
to  the  dietary.  In  cases  of  intestinal  stasis  an  examination  of  the 
stools  following  a  Schmidt  test  will  furnish  a  more  rational  basis  for 
feeding  such  patients. 

DIET  IN  PERITONITIS 

Acute  Peritonitis. — The  diet  in  acute  peritonitis  is  purely  of 
secondary  importance,  and  requires  consideration  only  until  opera- 
tive procedure  can  be  undertaken.  The  starvation  treatment  or  the 
so-called  Ochsner  treatment  may  be  employed  up  to  this  time.  The 
patient  is  placed  in  the  Fowler  or  sitting  position,  so  that  the  peri- 
toneal exudates  gravitate  toward  the  pelvis.     Neither  food  nor  drink 


DIET  ly  LIVER  DISEASES  495 

should  be  given  by  mouth.  An  ice-bag  is  placed  upon  the  abdomen. 
The  stomach  is  washed  out  frequently  to  prevent  vomiting,  and  con- 
tinuous enteroclysis,  according  to  the  method  of  Murphy,  should  be 
practised.  If  operation  is  not  undertaken  and  vomiting  has  ceased, 
fluids  may  be  given  in  a  few  days.  Foods  that  may  be  prescribed  are 
milk  and  lime-water,  diluted  broths,  and  egg-albumin  with  or  with- 
out brandy  or  sherry ;  only  very  small  quantities  should  be  taken  at 
a  time,  but  at  frequent  intervals;  gradually  plain  milk,  broth,  and 
gruels  may  be  added  to  the  list ;  solid  food  should  not  be  allowed  for 
several  weeks.  When  stimulants  are  required,  they  should  be  given 
in  the  form  of  whisky,  brandy,  or  champagne. 

Diet  in  Chronic  Peritonitis. — The  diet  in  chronic  peritonitis 
should  consist  of  boiled  meats,  eggs,  milk,  stale  bread,  toast,  or  crack- 
ers, and  vegetables,  onl.y,  however,  in  the  form  of  purees;  carbo- 
hydrates should  be  eaten  sparingly,  on  account  of  their  tendency  to 
ferment.  Food  should  be  eaten  in  small  quantities  at  regular  but 
frequent  intervals. 

DIET  IN  LIVER  DISEASES 

To  prevent  needless  repetition,  certain  general  dietetic  rules  will 
here  be  given  for  the  management  of  liver  diseases  in  general.  The 
theoretic  discussions  bearing  on  this  subject  have  become  so  numerous 
as  to  render  even  brief  consideration  of  them  impossible.  For  this 
reason  the  subject  will  be  dealt  with  here  only  from  a  practical  stand- 
point. 

The  group  of  symptoms  generally  classed  as  "biliousness"  are 
usually  the  result  of  overeating,  and  the  so-called  "bilious  attack" 
is  nothing  more  than  a  cry  of  the  liver  for  relief.  Many  individuals 
when  they  become  constipated  suffer  from  these  attacks.  These  two 
facts  furnish  the  indications  for  treatment:  rest  and  open  bowels. 
In  the  acute  attacks  all  that  is  necessary  is  a  restricted  diet  for  several 
days,  together  with  the  administration  of  calomel,  followed  by  a 
saline.  The  object  of  treatment  in  all  diseases  of  the  liver  should  be 
to  give  the  organ  as  little  work  to  do  as  possible.  It  should  not, 
however,  be  put  at  absolute  rest,  and  it  is  probably  not  possible  to 
accomplish  this  end  on  account  of  its  influence  on  general  metabolism. 
In  general,  a  simple,  well-mixed  diet  containing  protein,  fat,  and 
carbohydrates  is  indicated.  In  certain  diseases  in  which  the  func- 
tion of  the  liver  is  manifestly  impaired,  fat  and  carbohydrates  must 
be  restricted  or  even  omitted  entirely  for  a  few  days.  Both,  if  not 
promptly  disposed  of,  are  apt  to  undergo  changes  in  the  intestinal 
canal. 

Certain  articles  of  diet  are  known,  while  others  are  believed,  to  be 
injurious  in  diseased  conditions  of  the  liver.  Overeating  is  injurious, 
first,  on  account  of  the  overwork  it  necessitates;  and,  secondly,  be- 


496  DIET  IN  DISEASE 

cause  the  superfluous  food  is  apt  to  undergo  putrefaction.  The  re- 
sulting bacterial  products  are  believed  to  act  on  the  liver  in  much  the 
same  manner  as  does  alcohol.  The  excessive  use  of  alcohol  produces 
marked  changes  in  the  liver  in  certain  individuals.  This  has  been 
proved  by  experiments  on  animals.  In  a  series  of  experiments  per- 
formed by  the  authors  in  the  Pathologic  Laboratory  of  the  Johns 
Hopkins  Hospital,  Baltimore,  actual  cirrhotic  changes  in  the  liver 
were  induced  by  the  administration  of  alcohol.^  Some  persons  may 
take  alcohol  continuously  with  impunity.  If  taken  in  excessive  quan- 
tities, however,  over  sufficiently  prolonged  periods,  it  probably  in- 
variably produces  chronic  tissue  changes.  When  a  certain  amount 
is  taken,  it  seems  to  be  burnt  up  in  the  body  as  food ;  when  this 
limit  is  passed,  it  becomes  a  poison.  In  certain  fevers  enormous 
quantities  may  often  be  consumed  with  great  benetit.  Just  what 
amount  may  be  taken  with  safety  by  any  one  individual  is  not  known, 
and  is  dependent  in  large  degree  on  idiosyncrasy.  It  has  been  esti- 
mated that  two  ounces  of  alcohol  on  the  average  may  be  consumed 
as  a  food  in  twenty-four  hours.  The  form  and  the  amount  of  con- 
centration of  the  alcohol  are  important  factors  in  considering  the 
effect  of  alcohol  on  the  liver.  Whisky,  brandy,  and  similar  spirituous 
liquors,  taken  in  a  concentrated  form,  undoubtedly  produce  more 
marked  tissue  changes  in  the  liver  than  light  wines  or  beer. 

In  all  liver  diseases  alcohol  should  he  avoided  unless  specially  in- 
dicated as  a  tonic  or  stimulant.  In  any  case  it  should  be  given  well 
diluted.  A  well-matured  pure  whisky  well  diluted  with  water  is  to 
be  preferred,  and  this  only  in  the  smallest  possible  amount. 

Certain  foods  have  been  regarded  as  ''stimulating"  or  "irritat- 
ing" to  the  liver.  Among  these  are  peppers  of  various  kinds,  spices, 
mustards,  concentrated  meat  extracts  and  meat  broths,  and  the  sub- 
stances formed  in  roasted  and  baked  meats.  To  be  proscribed  are 
peppers,  radishes,  horseradish,  onions,  watercress,  and  celery.  Salt 
in  too  large  quantities  is  also  to  be  condemned.  Strong  coffee  and 
tea  are  harmful,  but  weak  tea  seems  to  be  well  borne  in  many  cases. 

In  severe  diseases  of  the  liver  the  diet  must  usually  be  restricted 
to  milk,  diluted  or  peptonized,  gruels,  albumin-water,  kumiss,  butter- 
milk, and  bland  broths,  such  as  oyster  broth.  Orange-juice  as  well  as 
lemonade  may  generally  be  allowed. 

In  the  milder  disease  and  during  convalescence  the  diet  need  not 
be  so  rigid,  and  lean  meat,  curd,  junket,  bread,  toast,  zwieback,  fresh 
fruit,  or  fruit  stewed  with  little  or  no  sugar,  may  be  allowed.  In 
the  chronic  cases  and  lighter  forms  the  following  articles  may  help  to 
make  up  the  dietary.  Milk,  variously  diluted  and  prepared,  butter- 
milk, curd,  kumiss,  custard,  junket,  eggs,  lean  meat,  if  beef  or  mutton, 
preferably  rare,  sweetbreads,  chicken,  squab,  liver,  the  soft  parts  of 

1  See  Welch,  The  Physiologic  Aspects  of  the  Liquor  Question. 


CATARRHAL  JAUNDICE  497 

oysters  and  the  more  digestible  forms  of  fish.  Fresh  green  vegetables 
and  green  salads  without  oil  are  permissible.  Small  quantities  of 
well-baked  or  boiled  mealy  potato  may  be  allowed  once  a  day,  for 
many  persons  do  not  relish  a  meal  that  does  not  contain  potato  in 
some  form.  The  starchy  foods  should  be  partaken  of  somewhat 
sparingly  bread,  toast,  zwieback,  pulled  bread,  and  biscuits  (crackers) 
may  be  permitted.  Small  quantities  of  cereal  foods  may  be  taken — 
rice,  sago,  and  tapioca,  when  sufficiently  well-cooked,  may  be  allowed. 
Fresh  fruit  is  a  valuable  adjunct  to  the  diet.  Oranges,  grape-fruit, 
ripe  peaches  or  pears,  grapes,  strawberries,  ripe  plums  of  the  most 
tender  varieties  may  all  be  taken.  Stewed  fruits  only  slightly  sweet- 
ened and  baked  apples  may  be  allowed  with  advantage.  If  there  is 
constipation,  stewed  prunes  are  useful.  Lemonade  may  be  taken  as  a 
beverage. 

Mineral  waters  may  be  drunk  freely  if  dropsy  is  not  present,  and 
are  best  taken  on  rising  and  between  meals.  Hot  water  is  a  valuable 
substitute  for  the  mineral  waters.  It  is  especially  useful  in  allaying 
thirst  when  there  is  dropsy. 

The  food  should  be  taken  slowly,  well  masticated,  and  never  in  too 
large  quantities.  If  necessary,  more  milk  may  be  given,  so  as  to  make 
large  amounts  of  other  food  unnecessary.  The  patient  should  lie 
down  directly  before  and  after  meals.  In  no  case  should  the  patient 
eat  immediately  after  taking' active  exercise. 

In  certain  chronic  conditions,  such  as  hyperemia,  fatty  degenera- 
tion, and  chronic  hepatitis,  exercise  is  to  be  taken  at  proper  times. 

In  summer  and  in  warm  climates  more  vegetables  are  to  be  allowed 
and  less  meat.  When  the  putrefaction  is  caused  b^^  torpidity  of  the 
liver,  it  may  sometimes  be  prevented  by  increasing  the  amount  of 
vegetables  and  by  the  use  of  laxatives. 

CATARRHAL  JAUNDICE 

During  the  acute  stage,  so  long  as  there  is  any  tendency  to  vomit 
or  while  dyspepsia  is  marked,  the  patient  should  be  kept  quiet  in 
bed.  The  diet  should  be  very  light  and  fluid.  Fat  is  especially  to 
be  avoided,  as  are,  of  course,  all  foods  that  are  either  chemically  or 
mechanically  irritating. 

Milk,  which  may  either  be  skimmed  or  diluted  with  lime-water  or 
mineral  waters  or  peptonized,  is  probably  the  most  useful  article  of 
diet.  On  account  of  the  fat  which  whole  milk  contains  it  is,  however, 
open  to  certain  theoretic  objections.  In  practice,  nevertheless,  it  is 
generally  well  borne.  Buttermilk  or  kumiss  may  also  be  used,  as  may 
beef-juice,  oj^ster-broth,  clam  bouillon,  albumin-water,  and  well-cooked 
and  strained  barley  gruel.  If  the  stomach  is  irritable,  food  should  be 
given  in  small  quantities  and  at  regular  intervals.  As  the  stomach 
becomes  tolerant  and  the  appetite  returns,  bread,  zwieback,  toast,  lean 
meat,  such  as  the  breast  of  chicken,  sweetbreads,  and  tender  steak  or 
32 


498  DIET  IN  DISEASE 

chops  may  be  administered.  Soups  thickened  with  barley  or  flour 
may  be  given,  and  the  lighter  forms  of  fish  may  also  be  allowed. 
Fruit,  well  cooked  and  without  too  much  sugar,  may  be  added  as  con- 
valescence progresses.  All  coarse  forms  of  vegetables  must  be  avoided, 
but  spinach,  asparagus  tips,  and  cauliflower  tops  may  be  given. 
Well-cooked  mashed  potatoes  may  be  allowed  in  moderate  quantities. 
The  meals  should  be  small  and,  if  necessarj^  may  be  given  frequently. 
During  convalesence,  when  the  appetite  returns  in  full  force,  the 
patient  should  be  cautioned  against  overeating.  For  several  months 
the  diet  should  be  guarded  and  all  irritating  and  coarse  articles  of 
food  avoided. 

Coffee  and  tea  should  be  forbidden  during  the  acute  stage,  but 
during  convalescence  they  may  be  allowed,  but  should  be  given  neither 
too  strong  nor  in  too  great  quantity.  Alcohol  is  best  avoided.  Fats, 
such  as  butter  and  cream,  should  be  withheld  longest  in  the  return  to 
a  full  diet.  If  an  excess  of  starch  or  of  sugar  is  taken,  disturbances 
are  certain  to  follow ;  if  fats  are  given  in  too  great  abundance  or  too 
early,  putrefactive  changes  are  apt  to  occur. 

^Mineral  water  may  be  drunk  freely .  during  the  course  of  the  dis- 
ease, and  the  bowels  should  be  kept  open.  Carlsbad  and  Vichy  are 
especially  to  be  recommended,  but  other  waters  may  be  used.  Plain 
carbonated  water  is  useful  as  a  beverage. 

Catarrhal  Jaundice  in  Children. — The  disease  is  rare  in  children 
under  two  years  of  age.  The  same  general  principles  of  diet  may  be 
adhered  to  as  when  the  disease  occurs  in  adults.  Fat,  starches,  and 
sugar  should  be  reduced  in  quantity,  and  rare  meat,  fruit,  and  milk 
more  plentifully  supplied.  If  vomiting  occurs,  milk  diluted  with 
lime-water  or  a  carbonated  water,  or  peptonized  milk  may  be  used. 
If  the  gastric  symptoms  are  severe,  the  diet  should  be  the  same  as 
that  for  acute  gastric  indigestion.  Calomel,  the  salines,  and  mineral 
waters  should  be  prescribed  to  keep  the  bowels  open. 

CONGESTION  OF  THE  LIVER 

Acute  Congestion. — The  treatment  depends  largely  on  the  cause. 
When  the  congestion  occurs  in  the  course  of  acute  diseases,  the  diet 
is  practically  the  same  as  that  of  the  associated  disease.  When  there 
is  pain,  rest  is  essential.  If  the  patient's  condition  warrants,  the 
diet  should  be  largely  restricted.  Skimmed  milk  or  milk  diluted  with 
alkaline  mineral  waters  is  the  best  diet.  Very  little  food  for  a  day 
or  two  and  then  increase  gradually.  Milk,  soups,  lean  meat  fruit, 
cooked  fruit,  soft  green  vegetables  and  bread  or  toast  should  form  the 
bulk  of  the  dietary.  All  irritating  foods,  coffee,  strong  tea,  and 
alcohol  are  to  be  avoided.     Salines  are  indicated  in  most  cases. 

Passive  Congestion  of  the  Liver. — The  diet  should  be  restricted 
and  the  same  general  principles  observed  as  directed  in  liver  disease 
in  general. 


DIET  IN  GALL-STONE  DISEASE  499 

ACUTE  YELLOW  ATROPHY 

The  diet  should  be  restricted;  usually  only  liquids  can  be  given, 
such  as  milk,  diluted  as  in  catarrhal  jaundice,  albumin- water,  etc. 
In  general  the  management  resembles  that  of  an  acute  fever. 

ABSCESS  OF  THE  LIVER 

In  the  early  stages  the  patient  should  be  put  at  rest  and  receive  a 
very  light  diet  of  milk,  gruels,  and  the  like.  After  operation  the 
diet  may  be  as  nutritious  as  possible,  bearing  in  mind  the  general 
principles  of  diet  in  liver  diseases. 

FATTY  LIVER 

The  diet  will  depend  upon  the  exciting  cause.  When  the  fatty 
liver  is  the  result  of  general  obesity,  the  treatment  should  be  along 
the  lines  indicated  for  that  condition.  When  it  is  due  to  tuberculosis 
or  to  other  chronic  infections,  the  diet  should  be  arranged  accord- 
ingly. In  the  severe  cachexias  that  mark  incurable  diseases  little  can 
be  done  in  the  way  of  diet. 

In  general  the  food  should  be  easily  digestible ;  milk,  lean  meat,  and 
eggs  are  mainly  to  be  relied  on.  Predigested  milk  and  meats  may  be 
of  value,  but  fats  and  oils  should  be  avoided. 

AMYLOID  LIVER 

This  is  usually  caused  by  long-standing  suppuration.  The  food 
should  be  as  easily  digestible  as  it  is  possible  to  make  it.  At  the  same 
time  the  largest  amount  of  protein  material  consistent  with  the  pa- 
tient's digestive  powers,  should  be  given. 

SYPHILIS  OF  THE  LIVER 

The  diet  should  be  arranged  according  to  the  general  principles 
laid  down  for  liver  diseases  in  general. 

DIET  IN  GALL-STONE  DISEASE 

Cholelithiasis  is  a  subject  of  ever-increasing  interest.  It  is  esti- 
mated that  about  10  per  cent,  of  the  population  of  Germany  have  gall- 
stones. Kehr  states  that  only  about  5  per  cent,  of  these  ever  give 
rise  to  serious  disturbances.  Numerous  theories  have  been  advanced 
regarding  the  cause  of  the  formation  of  gall-stones.  Errors  in  diet 
and  the  various  food  elements  have  been  considered  causative,  and 
have  led  to  the  establishment  of  various  dietaries.  Most  observers 
are,  however,  inclined  to  consider  the  prophylactic  measures  about 
to  be  described  of  value.  (For  an  exhaustive  discussion  of  this  sub- 
ject the  student  is  referred  to  the  article  by  Quincke  and  Hoppe- 
Seyler  in  Nothnagel's  Encyclopedia  of  Medicine,  which  has  been 
ably  edited  by  the  late  Dr.  Frederick  A.  Packard.) 

The  two  factors  that  in  all  probability  exert  the  most  influence  on 


500  DIET  TN  DISEASE 

the  formation  of  gall-stones  are  the  stasis  of  bile  and  the  inflammation 
of  the  bile-passages  and  gall-bladder.  To  this  end  anything  that  will 
increase  the  flow  of  bile  should  be  encouraged,  and  anything  that 
retards  it,  avoided.  To  obviate  the  latter  all  food  that  is  liable  to 
cause  indigestion,  with  the  attendant  dangers  of  putrefactive  changes 
setting  up  inflammatory  processes,  should  be  carefully  avoided. 

The  patient  should  lead  an  active,  if  possible  an  out-of-door,  life 
and  physical  exercise  should  be  a  part  of  the  daily  routine.  Horse- 
back-riding for  those  who  are  in  condition  and  who  can  afford  it  is 
excellent.  Walking,  fencing,  golf,  tennis,  and  swimming  are  helpful, 
and  where  these  are  not  enjoyed,  systematic  gymnastic  exercises  should 
be  prescribed.  Exercise,  if  the  motions  are  violent  enough,  acts  di- 
rectly by  forcing  the  bile  from  the  liver  and  gall-bladder,  and  in- 
directly by  increasing  the  movements  of  the  intestines. 

The  clothing  should  at  all  times  be  comfortably  loose.  Women 
especially  should  be  cautioned  in  regard  to  this  point.  The  corsets 
should  flt  loosely  and  be  suspended  from  the  shoulders,  so  as  to  take 
the  pressure  from  the  waist.  After  meals  the  clothing  should  be 
loosened,  so  as  to  relieve  the  abdominal  organs  from  pressure. 

Constipation  should  studiously  be  avoided.  The  diet  should  be  ar- 
ranged with  this  object  in  mind,  and  the  use  of  laxative  salines  is  to 
be  recommended  where  their  use  is  necessary.  Epsom  salts  and  sul- 
phate of  soda  are  of  especial  value  in  this  connection.  If  desired, 
the  saline  mineral  waters  may  be  substituted,  or,  for  those  who  can 
afford  it,  occasional  visits  may  be  made  to  various  mineral  springs. 

The  meals  should  be  taken  at  regular  intervals  not  too  widely  sepa- 
rated. Prolonged  fasting  should  never  be  permitted,  for  eating  in- 
creases the  flow  of  bile  while  fasting  causes  the  bile  to  be  stored  up 
in  the  gall-bladder.  Some  years  ago  Frerichs  contended  that  in 
cholelithiasis  the  meals  should  come  close  together.  Care  must,  how- 
ever, be  exercised  to  see  that  the  food  is  being  thoroughly  digested 
and  moved  along  the  intestinal  tract  normally.  Kehr  advises  a  sup- 
per to  be  taken  late  at  night.  Other  authors  have  advocated  waking 
the  patient  in  the  middle  of  the  night  to  administer  nourishment. 
This  last  would  seem  to  be  entirely  unnecessary.  Naunyn  insists  on 
the  importance  of  a  sufficiently  large  breakfast  and,  indeed,  a  large 
meal  after  any  fast.  The  average  American  breakfast  is,  however, 
sufficiently  large  in  almost  all  instances.  Care  should  be  taken  not 
to  err  in  the  opposite  direction  by  giving  more  food  than  can  be 
digested. 

In  the  choice  of  food  there  are  certain  things  to  be  avoided.  In 
the  first  place,  all  food  that  is  not  entirely  above  suspicion  or  that  is 
liable  to  set  up  putrefactive  changes  must  be  interdicted.  In  this 
category  are  to  be  placed  stale  fruits,  stale  fish  and  shell-fish,  over- 
ripe cheese,  and  the  like. 

Fat  should,  as  a  rule,  be  reduced  to  a  minimum,  for  there  is  con- 


DIET  IX  GALL-STONE  DISEASE  501 

siderable  clinical  evidence  to  show  that  the  abundance  of  fat  is  in- 
jurious in  gall-stone  disease,  as  well  as  in  other  disorders  of  the  liver. 
Whether  the  fat  acts  in  any  other  way  than  in  producing  bowel 
disturbances  is  a  question  that  has  not  yet  been  decided.  Herter  has 
recently  pointed  out  that  dogs  fed  for  mouths  on  a  diet  rich  in  fat 
and  low  in  proteins  showed  concretions  in  their  gall-bladders.  Fat, 
should,  however,  not  be  eliminated  from  the  dietary  altogether. 

Excesses  in  carbohydrates,  either  in  starches  or  in  sugar,  should 
be  carefully  avoided.  Anything  that  will  irritate  the  liver  should 
be  prohibited,  as  should  all  rich  and  complicated  dishes.  Any  food 
that  is  apt  to  cause  indigestion  is  to  be  regarded  as  unsuitable  for  the 
patient  with  gall-stones. 

Protein,  carbohydrates,  and  fat  should  go  to  make  up  the  dietary, 
which  should  consist  of  simple  food,  plainly  prepared,  with  care,  how- 
ever, to  avoid  a  monotonous  diet.  Meat  should  not  be  eaten  too 
freely,  and  only  the  leaner  varieties  should  be  used.  IMilk  and  eggs 
are  allowable,  but  if  the  milk  is  extremely  rich,  a  portion  of  the 
cream  should  be  removed.  Some  authors  forbid  the  yolk  of  eggs  as 
containing  too  much  fat. 

The  green  vegetables  and  fresh  fruits  are  suitable  articles  of  food 
and  may  be  partaken  of  freely.  Cereals  and  potatoes  may  be  used 
in  moderation,  but  not  where  there  is  "starch  indigestion."  Turnips, 
beets,  and  the  like  may  be  partaken  of  sparingly.  While  various 
authors  forbid  the  use  of  some  of  these,  it  is  probably  not  the  choice, 
but  the  quantity,  that  should  be  considered  in  this  connection. 

Bread,  rolls,  and  the  like  may  be  eaten  as  desired,  bearing  in  mind 
that  in  "starch  indigestion"  the  amount  should  be  limited.  Pastry 
and  any  but  the  plainest  cakes  should  be  omitted  from  the  diet. 
Harley  made  the  statement  that  he  believed  that  starch  puddings  and 
fat  bacon  caused  more  gall-stones  in  England  than  all  other  foods  put 
together.  Alcohol  should  be  avoided,  but  coffee  and  tea  may  be 
allowed  in  moderation.  The  drinking  of  hot  water  on  rising  and  at 
bedtime  has  been  advised,  as  well  as  the  various  mineral  waters  men- 
tioned in  connection  with  constipation. 

Coexisting  diseases  are  believed  to  exert  some  influence  on  the 
formation  of  gall-stones,  and  when  gout,  chronic  rheumatism,  diabetes, 
obesity,  or  dyspepsia  exists,  the  diet  should  be  regulated  accord- 
ingly. 

Rothchild  and  Rosenthal  have  shown  that  in  the  majority  of  cases 
of  cholelithiasis  a  hypercholesterinemia  is  present.  In  some  of  these 
patients  there  seems  to  be  a  cholesterin  diathesis  just  as  there  is  a 
uric  acid  retention  in  individuals  affected  with  a  gouty  diathesis. 
The  recognition  of  such  a  condition  is  important  since  secondary 
operations  in  gall-bladder  affections  might  be  avoided  by  proper 
dietetic  management.     They  point  out  that  since  the  cholesterin  con- 


502  DIET  IN  DISEASE 

tent  of  the  blood  is  dependent  upon  the  cholesterin  content  of  the 
food,  by  diminishing  the  latter,  one  can  correspondingly  diminish  the 
former  and  by  rendering  the  absorption  of  cholesterin  as  difficult  as 
possible  the  cholesterin  content  of  the  blood  will  be  lowered.  This 
can  be  done  by  placing  the  patient  upon  a  fat-free  diet,  which  ex- 
cludes lipoids  to  a  large  extent  and  renders  difficult  the  esterization 
of  the  free  cholesterin  in  the  food.  All  foods  rich  in  fats  are  ex- 
cluded. Butter  and  its  substitutes,  olive  oil,  eggs,  cream,  meat  and 
fish.  Beans  and  peas  are  also  excluded  on  account  of  their  contain- 
ing phylocholesterin.  On  a  strict  diet  of  this  kind,  practically  only 
vegetables  are  allowed,  any  kind  may  be  taken  together  with  cereals 
and  sugar.  Skimmed  milk  or  fat  free  buttermilk  may  also  be  used. 
The  majority  of  patients  will  not  adhere  to  this  diet  for  any  long 
period,  as  a  rule,  so  that  it  has  been  suggested  to  have  fast  and  feast 
day  periods.  For  three  or  four  days  a  week  the  patient  lives  on  a 
strict  fat-free  diet.  This  is  the  so-called  fasting  period.  For  the  next 
three  or  four  days,  dependent  on  the  grade  of  hypercholesterinemia, 
a  more  liberal  diet  is  permitted,  the  so-called  feast  days,  on  which  the 
patient  is  allowed  well  cooked  lean  meats  and  fish,  excluding  salmon, 
shad  and  blue  fish,  the  fat  content  of  which  is  high.  Oleomargarine 
is  allowed  instead  of  butter.  By  means  of  these  dietetic  restrictions 
the  authors  referred  to  have  been  able  to  reduce  the  hypercholester- 
inimia  and  apparently  have  solved  at  least  one  of  the  important  etio- 
logic  factors  of  chronic  cholelithiasis. 

CIRRHOSIS  OF  THE  LIVER 

Hypertrophic  Cirrhosis  (Hanoi's  Disease). — Hanot,  in  his  mono- 
graph on  the  disease  that  bears  his  name,  dismisses  the  subject  of  the 
diet  almost  in  a  word.  He  recommends  a  milk  diet  for  weeks  at  a 
time  where  it  is  well  borne.  Where  a  more  extensive  diet  is  in- 
dicated the  same  lines  may  be  followed  as  were  laid  down  for  cirrhosis 
in  general. 

Cirrhosis. — So  far  as  diet  is  concerned,  all  forms  of  cirrhosis  may 
be  treated  in  much  the  same  general  way.  Since  no  two  cases  are 
exactly  alike,  it  must  never  be  forgotten  that  each  case  requires  in- 
dividual consideration.  The  heart,  the  kidneys,  or  the  alimentary 
canal  may  be  involved,  and  ascites  may  be  present.  The  existence  of 
these  complications  materially  affects  the  management  of  the  case. 

Certain  cases  of  cirrhosis  are  due  to  the  long-continued  use  of 
alcohol,  highly  seasoned  food  in  excessive  (juantities,  and,  probably, 
to  chronic  intestinal  fermentations.  Certain  metallic  poisons  may 
also  cause  it. 

All  individuals  who  are  predisposed  to  cirrhosis, — those  who  come 
from  families  where  liver  disease  or  other  forms  of  cirrhotic  disease 
are  frequent, — should  be  cautioned  in  regard  to  the  diet  and  the  use 


DIET  ly  DISEASES  OF  THE  PAyCREAS  503 

of  alcohol.  Those  large  eaters  and  drinkers  or  those  who  suffer  from 
indigestion,  discomfort,  or  even  pain  over  the  region  of  the  liver, 
should  be  put  on  a  simple  diet,  composed  largely  of  milk ;  the  bowels 
should  be  kept  open  by  the  use  of  saline  mineral  waters ;  alcohol  should 
be  withheld  altogether  or  reduced  to  the  smallest  possible  amount. 
All  rich  foods  and  those  mentioned  as  irritating  the  liver  should  be 
avoided.  If  alcohol  is  given  up  and  the  patient  lives  correctly,  much 
can  often  be  done  in  the  early  stages  to  avert,  or  at  least  to  postpone, 
the  disastrous  consequences. 

Cases  without  Ascites, — When  the  disease  has  been  diagnosed, 
.  and  if  ascites  is  not  present,  the  patient  may  be  put  on  a  milk  diet  or 
a  diet  composed  largely  of  milk  and  milk  foods.  Kumiss  and  butter- 
milk are  very  useful.  Egg-albumin  and  cereal  gruels  may  also  be 
used.  Under  a  simple  diet  of  this  kind  the  gastric  symptoms  may 
abate  or  even  disappear.  The  saline  mineral  waters  and  potassium 
iodid  are  valuable  adjuncts  in  the  treatment.  The  consideration  of 
other  drugs  useful  in  this  condition  does  not  come  within  the  scope 
of  this  work.  When  recovery  has  set  in  a  simple  diet,  composed  of 
milk,  the  lean,  easily  digestible  meats,  preferably  broiled  steak  and 
chops,  chicken,  and  the  like,  eggs,  bread,  green  vegetables,  and  fruits, 
potatoes,  and  cereals,  if  desired,  are  allowable.  The  meals  should 
be  small  and  taken  at  ^  regular  intervals.  Hot  water  or  the  saline 
waters  may  be  taken  on  rising  and  an  hour  or  so  before  eating.  The 
general  principles  for  diseased  conditions  of  the  liver  already  de- 
scribed must  be  followed. 

Cases  with  Ascites, — The  selection  of  a  diet  for  these  cases  is  fre- 
quently a  matter  of  considerable  difficulty.  Rest,  salines,  and  a 
restricted,  somewhat  dry  diet  often  gives  great  relief.  When  the 
kidneys  are  in  reasonably  good  condition,  a  dry  diet,  such  as  in  recom- 
mended for  senile  heart,  may  be  tried.  Hot  water  may  be  sipped  on 
rising  and  at  various  intervals  during  the  day,  and  helps  to  flush  out 
the  waste-products  of  metabolism.  Should  kidney  sjTnptoms.  arise 
and  the  quantity  of  urine  be  greatly  lessened,  it  is  better  to  increase 
the  allowance  of  fluid. 

If  kidney  diseases  are  present,  it  is  not  wise  to  attempt  to  relieve 
the  ascites  by  withholding  fluids.  When  kidney  complications  arises, 
French  writers  and  others  recommend  a  diet  composed  largely  of 
milk,  on  the  ground  that  it  is  a  good  diuretic,  excreting  not  only  the 
fluid  itself,  but  a  portion  of  the  fluid  held  in  the  body  as  well.  (See 
also  Karell  Diet.) 

DIET  IN  DISEASES  OF  THE  PANCREAS 

Little  has  been  written  on  this  subject.  Attempts  at  feeding  pan- 
creas by  the  mouth  and  by  rectal  enemata  have  not  been  productive 
of  good  results.     It  has  been  suggested  that  when  the  diagnosis  of 


504  DIET  IN  DISEASE 

pancreatic  disease  has  been  made,  both  fats  and  carbohydrates  be 
withdrawn  from  the  diet,  as  they  are  apt  to  undergo  fermentation 
in  the  absence  of  the  pancreatic  juice.  The  bile  may,  however,  assist 
in  the  emulsification  of  fat,  and  pancreatic  extracts  or  taka-diastase 
may  be  given  by  the  mouth,  with  a  view  to  aiding  starch  digestion. 
Pancreatic  extract  ^s  best  given  in  salol-coated  pills. 

The  diet  should  consist  largely  of  milk,  which  may  be  peptonized, 
predigested  meat  solutions,  and  the  like. 

According  to  Dolinski,  the  pancreatic  secretion  is  increased  by  the 
ingestion  of  acids  and  acid  drinks.  Alkaline  drinks  diminish  the 
secretion  of  the  pancreas.  An  abundant  diet  causes  an  increase  in 
the  amount  of  the  secretion. 


DIET  IN  DISEASES  OF  THE  RESPIRATORY  ORGANS 

DIET  IN  PLEURISY 

The  diet  suitable  in  the  treatment  of  pleurisy  with  effusion  has 
been  the  subject  of  many  experiments.  The  two  principal  methods 
advocated  are:  (1)  To  give  the  patient  as  dry  a  diet  as  is  possible, 
in  the  hope  that,  by  restricting  the  amount  of  fluid  supplied  to  the 
blood,  the  absorption  of  the  fluid  effusion  will  be  hastened.  It  has 
also  been  recommended  that  ordinary  table  salt  be  taken  in  large 
quantities,  on  the  principle  that,  owing  to  the  increased  density  of  the 
blood,  a  more  rapid  absorption  will  take  place.  Schroth's  "dry 
cure"  has  also  been  recommended.  (2)  The  second  plan,  advocated 
especially  by  certain  French  writers,  is  to  place  the  patient  on  an 
exclusive  milk  diet,  in  much  the  same  manner  as  described  in  the 
Milk  Cure.  This  is  said  to  increase  the  excretion  of  urine,  and  also 
to  cause  the  absorption  of  the  effusion.  The  return  to  a  general  diet 
should  be  gradual.  Practically  either  plan  may  be  followed,  accord- 
ing to  the  condition  of  the  patient.  If  there  is  fever  or  complicating 
kidney  or  heart  disease,  the  milk  diet  is  to  be  preferred.  If  there  are 
no  complicating  diseases  and  no  fever,  ordinary  diet  with  a  lessened 
amount  of  fluids  should  be  prescribed.  No  soups,  but  little  coffee,  tea, 
or  other  beverages,  and  as  small  an  amount  of  water  as  the  patient 
can  comfortably  get  along  on  should  be  allowed.  Large  effusions  are 
better  removed  by  aspiration  than  by  diet, 

DIET  IN  EMPYEMA 

The  dietetic  management  of  empyema  is  the  same  as  that  of  any 
septic  condition.  If  there  is  fever,  the  diet  should  be  that  advised  in 
the  treatment  of  fevers  in  general.  If  there  is  little  or  no  fever,  the 
diet  should  be  similar  to  that  recommended  in  the  early  stages  of 
tuberculosis.  Oilman  Thompson  advises  a  diet  coiltaining  as  much 
fatty  food  as  the  patient  can  take  as  best  meeting  the  demands  made 


DIET  IX  DISEASES  OF  THE  RESPIRATORY  ORGANS  505 

on  the  system  by  the  excretion  of  such  large  quantities  of  pus.  Foods 
that  cause  the  generation  of  gas  in  the  intestine  should  be  avoided. 
This  usually  arises  from  an  excess  of  carbohydrate  food,  but  may  also 
be  caused  by  the  ingestion  of  large  quantities  of  fat.  If  .there  is 
marked  tympanites,  the  embarrassment  of  the  respiration  is  increased. 

LARYNGISMUS  STRIDULUS 

Attacks  may  be  brought  on  by  overfeeding,  by  the  ingestion  of 
indigestible  articles  of  food,  and  by  constipation.  The  diet  should 
be  carefully  supervised,  and  the  same  general  indications  met  as  in 
rachitis. 

LARYNGITIS 

In  chronic  inflammations,  especially  tuberculous  laryngitis,  certain 
dietetic  measures  may  be  employed  that  will  give  considerable  relief 
to  the  patient.  Hard  and  dry  toasts  and  the  like  should  not  be  eaten, 
as  they  give  rise  to  pain  on  being  swallowed.  For  the  same  reason 
highly  seasoned  foods  are  to  be  avoided.  Only  semisolid  or  liquid 
food  should  be  eaten.  ]\Iilk,  custards,  junket,  soups  and  gruels,  raw 
oysters,  raw  eggs,  scraped  beef,  and  the  like  are  the  most  suitable 
articles  of  diet.  To  allay  the  irritation  in  the  larynx  Loomis  advises 
that  a  raw  egg  be  sucked  from  the  shell.  If  there  is  much  pain  on 
swallowing  codein  or  cocain  solutions  should  be  applied  locally  be- 
fore feeding.  A  tablet  containing  ^4  of  a  grain  of  cocain  may  be 
placed  on  the  back  of  the  tongue  and  allowed  to  dissolve.  This  is 
generally  effective,  and  has  the  advantage  that  the  patient  can  use  it 
himself. 

Difficulty  in  swallowing  may  sometimes  be  overcome  by  the  follow- 
ing two  methods :  By  allowing  the  patient  to  lie  flat  on  a  lounge  with 
his  face  over  the  edge.  Food  is  to  be  sucked  through  a  tube  from  a 
vessel  placed  immediately  below.  The  second  method  consists  in 
directing  the  patient  to  lean  forward  while  eating.  Sajous  (quoted 
from  Thompson)  says  that  this  latter  posture  causes  the  food  to  pass 
down  along  the  pyriform  sinuses,  thus  avoiding  the  upper  portion  of 
the  larynx,  contact  with  which  causes  the  severe  pain  experienced 
during  deglutition  in  advanced  cases  of  laryngitis. 

DIET  IN  ASTHMA 

Asthma  usually  occurs  in  markedly  neurotic  individuals,  who  are 
apt  to  exhibit  other  neuroses,  such  as  gastric  and  intestinal  disorders. 
Various  forms  of  food — e.  g.,  the  starches  and  sugars — have  been  said 
either  to  cause  or  to  predispose  the  individual  to  asthma. 

As  a  matter  of  fact,  many  attacks  of  asthma  are  brought  on  by 
indigestion,  this  usually  being  directly  traceable  to  some  error  in  diet. 
So  patent  is  this  fact  that  certain  cases  are  classed  as  "peptic"  or 
"gastric"  asthma. 

Any  food  that  causes  indigestion  should  be  avoided.     Patients  usu- 


506  DIET  IN  DISEASE 

ally  learn  by  experience  what  they  can  and  what  they  can  not  digest. 
Some  curious  idiosyncrasies  occur:  For  example,  in  one  patient  rice 
may  cause  indigestion — even  when  the  most  minute  quantities  are 
introduced  into  his  food  without  his  knowledge  an  attack  of  indiges- 
tion and  subsequently  of  asthma  may  supervene.  These  idiosyncra- 
sies exist,  of  course,  in  others  besides  asthmatics,  and  many  remarka- 
ble stories,  some  well-authenticated,  are  told  in  this  connection.  (See 
Food  Allergy.) 

The  asthmatic  should  live  a  quiet,  well-regulated  life.  If  there  is 
any  gastric  or  intestinal  derangement,  it  should  carefully  be  treated. 
The  diet  should  be  light  and  nutritious,  and  should  be  taken  at  regular 
intervals.  The  meals  should  be  of  a  size  to  be  easily  digested.  Vio- 
lent exercise  of  all  kinds  should  be  prohibited. 

The  foods  most  suitable  for  the  asthmatic  are  the  lighter  kinds  of 
fish  and  meat — the  white  meat  of  chicken,  roast-beef,  beef-steak,  chops, 
and  mutton.  The  most  easily  digested  vegetables,  such  as  spinach, 
asparagus-tips,  cauliflower  tops,  baked  potatoes,  and  the  like,  may  be 
taken.  Cereals  and  whole-wheat  bread  may  be  used  in  moderation. 
In  most  cases,  plain  desserts  may  be  allowed.  Pork,  cheese,  heavy 
cakes,  pastry,  and  all  similar  indigestible  articles  of  diet,  should  be 
avoided.  Fats,  sugars,  and  starches  should  be  taken  in  moderation, 
if  at  all.  Experience  will  generally  prove  the  best  guide  as  to  what 
is  suitable.  Foods  that  are  apt  to  cause  flatulence  are  best  avoided. 
A  diet  like  that  advised  in  high  blood  pressure  often  affords  relief. 

Dinner  should  be  taken  in  the  middle  of  the  day,  and  the  supper 
should  be  light.  Eating  at  night  should  be  discountenanced.  Tea 
and  coffee,  if  they  do  not  cause  gastric  disturbance,  may  be  taken  in 
moderation.  Strong  coffee  has  been  credited  with  warding  off  at- 
tacks; for  this  purpose  two  or  three  cups  of  strong  coffee  are  to  be 
taken  just  before  a  threatened  attack. 

In  the  weaker  patients  alcohol  may  be  allowed,  best  given  in  the 
form  of  good  matured  whisky.  Beer  and  ales  should  be  avoided  by 
most  patients.  Every  case  of  asthma  should  be  studied  carefully  in 
order  to  learn  what  food  is  and  what  is  not  harmful.  All  asthmatics 
probably  give  up  many  articles  of  diet  that  are  in  reality  indicated 
in  their  condition, 

DIET  IN  EMPHYSEMA 

Patients  with  emphysema  should  seek  to  prevent  flatulence  and 
constipation.  All  indigestible  foods  should  be  avoided,  and  the  diet 
should  be  along  the  sa-me  lines  as  indicated  in  asthma.  Starches  and 
sugar  should  be  taken  only  in  moderate  quantities,  as  otherwise  they 
may  ferment  and  give  rise  to  flatulence;  the  dyspnea  that  it  is  apt 
to  bring  on  may  be  a  source  of  great  discomfort.  In  the  later  stages 
milk  is  found  to  agree  better  than  any  other  food.  Cod-liver  oil, 
when  it  agrees  with  the  patient,  is  to  be  recommended.     The  meals 


DIET  IX  DISEASEIS  OF  THE  RESPIRATORY  ORGANS  507 

should  be  small  enough  to  be  easily  digested,  and  the  heaviest  meal 
should  be  taken  in  the  middle  of  the  day. 

DIET  IN  CHRONIC  BRONCHITIS 

The  dietetic  management  of  chronic  bronchitis  is  similar  to  that 
advised  in  the  early  stages  of  tuberculosis.  In  the  dryer  forms  de- 
mulcent drinks  are  useful,  and  hot  flax-seed  tea,  sweetened  with  sugar 
and  flavored  with  lemon-juice,  should  be  taken  in  sufficiently  large 
quantities  and  is  particularly  effective.  Hot  drinks  of  various  kinds 
may  be  used,  and  are  especially  useful  in  temporarily  relieving 
troublesome  cough.  Hot  milk  or  hot  lemonade,  or,  if  stimulants  are 
indicated,  whisky  and  glycerin,  may  be  given. 

DIET  IN  HEMORRHAGE  FROM  THE  LUNGS 

When  a  patient  has  had  a  hemorrhage  from  the  lungs  he  should 
immediately  be  put  to  rest  and  kept  absolutely  quiet.  If  the  hemor- 
rhage has  been  severe  and  the  patient  is  in  danger  of  collapse,  in  ad- 
dition to  the  usual  morphin  injections,  normal  salt  solution  may  be 
given  by  the  rectum  or  subcutaneously. 

The  food  should  be  liquid  in  form.  Peptonized  or  plain  milk,  liquid 
beef  peptonoids  or  similar  preparations,  fresh  beef -juice,  bouillon,  and 
the  like  may  be  used,  and  should  be  given  in  small  quantities  at  regu- 
lar intervals — two  or  three  ounces  may  be  given  every  two  or  three 
hours.  If  there  is  a  tendency  to  vomit,  food  may  be  given  by  the 
rectum. 

To  allay  thirst  only  small  quantities  of  fluid  should  be  given  at 
a  time.  Later,  when  the  stomach  is  tolerant,  larger  quantities  may 
be  prescribed. 

If  there  is  no  recurrence  of  the  hemorrhage  and  the  condition  of 
the  stomach  permits,  a  rapid  return  should  be  made  to  an  ordinary 
diet.     Meat  should  be  given  in  abundance  to  counteract  the  anemia. 

DIET  IN  PNEUMONIA 

In  pneumonia,  feeding  is  of  the  greatest  importance.  The  patient's 
strength  must  be  fostered;  for  the  better  the  nutrition  is  maintained, 
the  more  likely  will  the  patient  be  to  withstand  the  effects  of  the 
disease.  Formerly,  owing  to  energetic,  but  often  misdirected,  treat- 
ment, many  patients  died  in  the  early  stages  of  convalescence.  The 
French  writers  described  their  patients  as  having  "died  cured" — 
mort  gueri. 

The  same  general  principles  of  feeding  should  be  followed  as  are 
indicated  in  all  acute  fevers.  During  the  course  of  the  disease  the 
patient  should  receive  an  abundance  of  water  in  addition  to  the 
liquid  food  supplied.  Plain  water  or  any  carbonated  water  that  the 
patient  may  desire  should  be  given.     Milk  and  seltzer  may  be  allowed 


508  DIET  IN  DISEASE 

freely.  Lemonade,  or  orangeade,  or  water  flavored  with  tamarinds 
may  serve  to  lend  variety.  The  "imperial  drink"  (the  recipe  for 
which  appears  at  the  end  of  this  book)  may  also  be  given. 

During  the  height  of  the  disease  milk  should  form  the  basis  of  the 
diet.  This  may  be  peptonized  or  diluted  with  lime-water.  Albumin- 
water,  wine  whey,  malted  milk,  beef -juice,  Eskay's  food,  and  similar 
preparations  may  be  employed  when  milk  is  not  well  borne.  Predi- 
gested  liquid  beef  preparations  may  be  used  both  for  their  stimulating 
effects  and  as  a  food.  They  should  always  be  diluted  freely  with 
water,  unless,  because  of  vomiting,  a  concentrated  food  is  indicated. 

Food  should  be  given  at  regular  intervals  of  from  two  to  four 
hours,  according  to  the  patient's  condition  and  the  amount  he  is  able 
to  take  at  one  time. 

Constipation,  flatulence,  and  vomiting  are  to  be  avoided  wherever 
possible.  If  they  do  occur,  efforts  should  at  once  be  made  to  relieve 
the  condition. 

In  most  eases  starches  and  sugars  are  best  omitted  from  the  diet. 
Fruit  may  be  allowed  at  any  time  during  the  disease,  and  is  of  special 
benefit  during  convalescence.  Most  grateful  during  the  severe  stage 
are  orange-juice,  lemonade,  grape-fruit,  and  grapes.  During  con- 
valescence ripe  peaches  or  pears  in  season  may  be  added  to  the  diet. 
The  return  to  a  general  diet  should  be  made  gradually,  and  no  solid 
food  should  be  allowed  until  the  fever  has  subsided.  Then  the  gen- 
eral dietetic  rules  for  convalescents  may  be  followed. 

Pneumonia  patients  show  a  wonderful  tolerance  for  alcohol,  and  it 
is  apparently  utilized  by  the  body  as  a  food  as  well  as  a  stimulant. 
Large  quantities  may  often  be  taken  without  producing  any  symptoms 
of  intoxication.  Should  they  occur,  it  is  an  evidence  that  the  dose 
has  been  too  large.  Alcohol  should  not  be  prescribed  as  a  routine 
measure,  but  should  be  ordered  as  soon  as  the  heart  begins  to  flag. 
The  indication  for  its  use  may  generally  be  determined  by  ausculta- 
tion before  either  the  symptoms  or  the  pulse  point  to  the  need  for  it. 
It  should  be  given  at  once  when  the  first  sound  of  the  heart  becomes 
prolonged  and  weaker.  In  weak  individuals,  whatever  their  age,  es- 
pecially in  patients  over  fifty,  alcohol  may  be  begun  early.  The  dose 
for  adults  is  one-half  an  ounce  of  pure  whisky,  sufficiently  diluted, 
every  four  hours;  this  may  be  increased  when  necessity  arises.  In 
alcoholic  subjects  it  should  be  given  regularly.  If  it  is  withdrawn, 
delirium  or  collapse  may  ensue.  The  usual  care  should  be  observed  in 
determining  whether  the  stimulant  is  doing  good  or  harm.  It  is  best 
given  in  the  form  of  pure  matured  whisky,  but  champagne,  brandy,  or 
rum  may  occasionally  be  substituted  when  these  are  better  borne. 
In  all  cases  they  should  be  well  diluted  with  plain  or  carbonated 
water. 

Pneumonia  in  Children. — The  same  general  plan  is  to  be  followed 


DIET  IN  DISEASES  OF  THE  RESPIRATORY  ORGANS  509 

as  when  the  disease  occurs  in  adults,  and  both  lobar  pneumonia  and 
bronchopneumonia  require  the  same  dietetic  management. 

The  food  should  be  given  at  regular  intervals,  or  if  the  child  is  at 
the  breast,  it  should  be  nursed  at  regular  intervals.  If  a  child  at  the 
breast  is  too  weak  to  nurse,  the  milk  may  be  pumped  out  and  given 
by  means  of  a  stomach-tube  or  a  spoon.  The  stomach-tube  should 
not,  however,  be  used  in  pneumonia  except  as  a  last  resort. 

AYhen  infants  are  fed  on  modified  cows'  milk,  the  milk  should  be 
further  diluted  with  lime-water.  Food  should  not  be  given  oftener 
than  every  two  hours,  and  if  a  sufficient  quantity  is  taken,  the  interval 
may  be  lengthened  to  three  or  four  hours.  Milk  is  the  most  important 
food,  and  may  be  diluted  with  lime-water  or  with  carbonated  water. 
It  may  be  peptonized  partially  or  completely,  or  be  prepared  with 
the  Peptogenic  Milk  Powder,  with  Eskay's,  IMellin's,  or  similar  foods, 
or  malted  milk  may  be  used.  Buttermilk,  plain  or  prepared  after  the 
method  directed  in  the  section  on  Infant  Feeding,  may  be  tried. 
Kumiss  is  often  retained  where  plain  milk  is  rejected.  If  milk  is 
not  well  borne,  barley  or  oatmeal  gruels  may  be  used  by  way  of  variety. 
If  these  cause  flatulence,  they  should  be  avoided.  Albumin-water 
and  fresh  beef-juice  are  useful  foods,  and  such  preparations  as 
Panopepton,  liquid  beef  peptonoids,  and  predigested  beef  are  of  great 
service  when  other  foods  are  not  well  retained  or  assimilated.  Beef 
broth  or  other  meat  broths  may  occasionally  be  given. 

The  problem  of  feeding  children  suff:ering  from  pneumonia  is  fre- 
quently a  very  difficult  one,  for  while  they  may  take  a  food  readily, 
they  may  refuse  it  the  next  time  it  is  offered  or  vomit  it  if  taken. 
When  milk  is  well  borne,  it  should  constitute  the  diet,  but  where  it  is 
not,  the  physician  must  have  as  many  resources  as  possible.  From 
one  to  six  ounces,  according  to  the  age  and  condition  of  the  patient, 
may  usually  be  given  at  a  time,  but  it  may  at  times  be  necessary  to 
give  the  food  in  teaspoonful  or  tablespoonful  quantities. 

If  there  is  much  vomiting,  equal  parts  of  lime-water  and  cinnamon- 
water  may  be  given  to  great  advantage.  A  teaspoonful  of  this  mix- 
ture fifteen  minutes  before  feeding  may  allow  the  food  to  be  retained 
where  it  would  otherwise  be  rejected. 

Water  should  in  all  cases  be  offered  the  child  from  time  to  time, 
and  the  mistake  of  forcing  the  child  to  take  food  when  it  wants  only 
a  drink  of  water  should  be  avoided.  If  there  is  no  flatulence,  the 
carbonated  waters  are  often  very  well  borne. 

Alcoholic  stimulants  are  generally  needed  and  are  well  borne. 
Whisky  or  brandy  diluted  with  at  least  eight  parts  of  water  may  be 
given,  a  little  sugar  or  glycerin  being  added  to  overcome  the  sharp 
taste  and  render  it  more  palatable.  In  pneumonia,  as  in  other  dis- 
eases, alcohol  is  borne  better  when  it  is  given  in  small  quantities  and 
frequently,  than  when  larger  doses  at  greater  intervals  are  prescribed. 


510  DIET  IN  DISEASE 

The  average  interval  is  two  hours,  but  it  may  be  given  hourly  or  even 
more  frequently  when  occasion  demands, 

DIET  IN  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

DIET  IN  DISEASES  OF  THE  HEART 

Diet  in  Acute  Heart  Disease. — In  acute  endocarditis  and  peri- 
carditis the  diet  may  be  difficult  to  arrange  satisfactorily.  In  gen- 
eral, it  should  be  ordered  as  in  any  acute  infectious  disease,  and  if 
there  is  broken  compensation  and  edema,  the  suggestions  made  below 
for  the  same  stage  of  chronic  disease  should  be  followed. 

Diet  in  Chronic  Heart  Disease. — This  may  be  considered  under 
two  heads,  the  stage  of  compensation  and  the  stage  of  broken  com- 
pensation, and  a  few  words  may  be  added  to  cover  the  period  of 
threatened  rupture  of  compensation. 

During  the  period  of  perfect  compensation  the  patient  should  ob- 
serve the  general  rules  which  apply  to  all  patients  with  heart  disease. 
The  following  of  these  will  in  many  eases  postpone  the  stage  of  broken 
compensation.  Many  patients  are  careless,  and  it  is  not  until  the 
first  symptom  of  threatened  rupture  that  they  can  be  induced  to 
take  care  of  themselves.  In  addition  to  food  it  is  highly  important 
that  the  patient  should  avoid  hurry,  worry,  and  irregularity  of  life. 

The  meals  should  be  small — more  should  never  be  given  than  the 
patient  can  easily  digest.  If  the  stomach  is  overloaded,  the  diaphragm 
is  pushed  up  and  displaces  the  heart,  and  this  may  occasion  palpita- 
tion and  dyspnea.  If  the  meals  are  too  large,  the  residue  of  any  di- 
gested food  in  the  intestine  may  undergo  fermentation  and  cause 
flatulence,  with  its  attendant  disagreeable  symptoms. 

The  meals  should  be  simple  and  well  cooked.  Improperly  prepared 
food  is  a  cause  of  indigestion,  and  may  produce  flatulence  or  dis- 
comfort. The  food  should  be  of  a  kind  that  is  easy  of  digestion.  A 
sufficiently  long  interval  should  be  allowed  to  elapse  between  meals, 
and  eating  between  meals  should  be  strictly  prohibited,  as  even  small 
portions  of  food  taken  while  digestion  is  in  progress  may  give  rise 
to  flatulence  in  these  patients. 

The  meals  should  all  be  of  about  equal  size ;  while  the  evening  meal 
may  be  a  little  smaller  and  lighter  than  the  others,  and  the  principal 
meal  should  be  taken  at  midday,  there  should,  as  has  been  said,  be  but 
comparatively  little  difference  in  their  size,  and  the  patient  should  be 
instructed  carefully  in  this  regard. 

The  food  should  not  be  taken  too  hot  nor  too  cold.  The  amount  of 
food  and  its  choice  should  be  largely  that  of  a  person  of  the  same  size 
in  health.  The  amount  of  protein  should  be  about  120  grams  per 
day  for  the  average-sized  person,  and  this  may  often  be  reduced  to 
advantage.  In  case  the  kidneys  are  affected,  it  may  still  further  be 
reduced — some  20  to  40  grams.     The  amount  can  be  regulated  by 


DISEASES  OF  THE  CIRCULATORY  SYSTEM  511 

careful  observation  of  the  patient.  The  aim  should  be  to  get  the 
patient  to  normal  weight  and  keep  him  there,  to  have  as  perfect  diges- 
tion as  possible,  and,  above  all,  to  avoid  constipation.  The  remainder 
of  the  diet  should  consist  of  the  usual  quantities  of  fat  and  carbo- 
hydrate. If  the  patient  is  gaining  in  weight,  the  total  amount  of 
food  may  be  diminished,  and  especially  the  carbohydrates.  If  these 
latter  cause  flatulence,  or  any  other  gastric  or  intestinal  symptoms, 
they  should  be  reduced. 

All  highly  seasoned  food  and  the  condiments  in  general  should  be 
omitted  from  the  diet,  as  they  tend  to  stimulate  the  appetite  of  the 
patient,  and  may  cause  him  to  take  more  food  than  it  is  necessary  or 
desirable  for  him  to  have. 

Stews  and  fancy  dishes  should  also  be  omitted,  as  should  the  foods 
usually  classed  as  difficult  of  digestion,  such  as  fried  foods  and  the 
like. 

The  amount  of  fluid  should  not  be  too  large  nor  too  small.  The 
total  fluid  should  perhaps  not  exceed  six  to  eight  glasses  a  day,  with 
an  occasional  water-drinking  day.  Tea  and  cofl:'ee  may  be  taken  in 
moderation  if  they  agree.  In  some  individuals  they  may  be  omitted 
to  advantage,  and  these  are  the  persons  who  suffer  from  flatulence, 
indigestion,  wakefulness,  etc.,  after  the  ingestion  of  either. 

Tobacco  is  best  forbidden,  except  in  seasoned  smokers,  in  whom  the 
tolerance  for  it  has  been  well  established  by  years  of  indulgence. 
Even  in  these  the  amount  should  be  limited. 

The  diet  should  consist  largely  of  milk  and  of  dishes  made  from 
this  food,  eggs,  rare  meats,  especially  mutton  and  beef,  poultry,  fish, 
and  oysters.  Well-baked  bread,  rolls,  or  biscuits,  which  are  never 
to  be  eaten  warm,  and  cereals  in  moderate  quantities  may  be  allowed. 
Well-cooked  potatoes,  spinach,  asparagus  tips,  cauliflower  tops,  and 
similar  vegetables  may  be  taken,  all  stalks  being  avoided. 

The  diet-list  should  be  simple,  and  such  as  will  not  require  burden- 
ing the  patient  with  complicated  directions. 

As  compensation  becomes  impaired  numerous  disorders  of  digestion 
occur  and  require  care  and  attention.  The  patient  with  heart  disease 
may  develop  a  distaste  for  food,  and  this  will  often  tax  the  ingenuity 
of  the  physician. 

As  blood  stasis  sets  in,  constipation  is  apt  to  occur.  Hypostatic 
congestion  of  the  liver  comes  on,  causing  lessened  metabolism  and 
consequently  interfering  greatly  with  the  general  nutrition.  The 
stomach  and  intestine  are  affected,  and  a  chronic  catarrhal  condition 
of  both  is  generally  present. 

The  quantity  of  fluid  given  should  now  be  regulated  carefully, 
neither  too  much  nor  too  little  being  given.  A  glass  of  Vichy  half 
an  hour  before  eating  will  help  to  prepare  the  stomach  for  a  meal,  and 
will,  as  a  rule,  be  excreted  promptly.  Fluid  is  absolutely  necessary 
for  metabolic  changes,  and  may  be  taken  in  the  form  of  the  "imperial 


512  DIET  lis'  DISEASE 

drink,"  elsewhere  described,  between  meals.  A  glass  of  hot  water 
flushes  out  the  body,  and,  as  it  is  rapidly  excreted,  does  not  add 
materially  to  the  amount  of  fluid  present. 

In  the  Oertel  treatment  of  heart  disease  the  fluids  are  allowed 
only  in  a  very  limited  degree.  If  the  patient  is  on  a  milk  diet, 
other  fluids  besides  milk  should  be  given  in  comparatively  small 
quantities. 

If  edema  is  severe,  the  food  may  be  given  in  as  concentrated  a 
form  as  possible.     (See  also  Karell  Diet.) 

If  flatulence  is  troublesome,  fats,  starches,  and  sugars,  as  well  as 
beer,  pastry,  and  stews,  are  to  be  avoided.  No  solid  food  should  be 
taken  between  meals.  Coffee  or  tea  taken  with  the  meals  may  give 
rise  to  flatulence.  They  may,  however,  in  some  cases  be  taken  during 
the  day,  at  a  time  when  the  stomach  is  empty ;  they  should  be  freshly 
prepared  and  should  never  be  strong.  Only  such  quantities  of  food 
as  the  patient  can  digest  should  be  allowed,  and,  if  necessary,  diges- 
tion may  be  aided  by  giving  essence  of  pepsin  or  other  digestives.  In 
some  cases  a  milk  diet  may  become  necessary.  Sometimes  buttermilk, 
or  whole  milk  that  has  been  inoculated  with  the  lactic  acid  bacillus, 
is  of  great  service. 

Sudden  dilataiion  of  the  heart  occurring  during  or  following  any 
acute  disease  requires  rest  and  a  milk  diet. 

Palpitation  and  dyspnea  are  often  caused  by  the  ingestion  of  too 
abundant  meals ;  if  persistent,  the  food  should  be  given  in  smaller 
quantities  and  at  shorter  intervals.  Four  or  five  small,  instead  of 
three  large,  meals  may  be  taken  at  regular  intervals,  or  a  milk  diet 
may  be  ordered  for  a  time.  The  general  management  may  be  such 
as  has  been  suggested  for  flatulence.  Tea,  eoft'ee,  and  tobacco  should 
be  avoided,  and  effervescing  drinks  may  also  be  omitted.  If  there  is 
constipation,  stewed  fruits,  especially  prunes  or  figs,  are  useful. 

Gastric  disturhances  are  best  met  by  rest  and  a  milk  diet  for  a 
time,  with  a  gradual  return  to  the  ordinary  diet  or  a  diet  such  as  is 
advised  for  cases  of  gastric  catarrh.  Much  relief  frequently  follows 
the  drinking  of  a  glass  of  hot  water  or  of  Vichy  half  an  hour  before 
a  meal. 

As  ruptured  compensation  is  accompanied  by  effusion,  something 
must  be  said  with  special  reference  to  the  removal  of  fluids  from  the 
body.  Here,  indeed,  feeding  is  a  difiScult  task,  for  the  patient  usu- 
ally has  a  disgust  for  food.  As  Broadbent  says,  the  object  is  to  keep 
down  the  volume  of  the  blood  while  maintaining  its  quality.  If  the 
patient  is  very  ill,  nourishment  may  be  administered  every  three 
hours.  If  he  is  able  to  be  about,  it  will  often  be  well  to  allow  him  to 
take  his  meals  with  the  family  at  the  regular  meal-time.  He  may  be 
given  chicken,  tender  meats,  fish,  oysters,  junket,  and  other  forms  of 
light  food.  "When  but  little  is  taken  at  the  regular  meal-time,  food 
may  be  given  between  the  meals,  at  regular  periods,  time  being  al- 


DISEAiiES  OF  THE  CIRCULATORY  SYSTEM  513 

lowed  for  complete  digestion  to  take  place.  Milk,  albumin-water,  egg 
and  milk,  soup,  or  beef-tea  in  small  quantities  are  useful  for  this 
purpose.  Broadbent  recommends  meat  or  chicken  jelly  or  meat  ex- 
tracts, for  their  stimulating  effect  on  the  heart.  Potted-meat  sand- 
wiches or  meat  pulp,  prepared  as  directed  for  tuberculous  patients, 
may  be  given.  In  Germany  raw  ham  is  sometimes  prescribed.  Con- 
stipation may  often  be  avoided  by  adding  stewed  fruit,  prunes,  or 
figs,  or  vegetable  purees,  all  in  small  quantities,  to  the  diet.  If  nec- 
essarj^  predigested  foods  may  be  used. 

Fluids  other  than  milk  and  soups  should  be  +aken  in  as  small  quan- 
tities as  possible.  "Imperial  drink"  or  hot  water,  as  previously  sug- 
gested, may  be  given  to  quench  the  thirst. 

HEART  LESIONS  IN  CHILDREN 

The  diet  is  essentially  the  same  as  that  for  adults.  Children  who 
are  able  to  be  about  require  careful  supervision,  the  treatment  being 
along  the  same  general  lines  as  were  laid  down  for  adults.  Less  food 
is  required  than  in  health,  and  the  meals  should  be  smaller.  Care 
should  be  exercised  to  see  that  the  food  is  eaten  slowly  and  well 
masticated.  The  diet  should  consist  largely  of  milk,  eggs,  and  meat, 
with  or  without  a  cereal,  and  vegetables,  the  last  being  of  the  more 
easily  digested  varieties,  such  as  well-cooked  spinach,  asparagus-tips, 
and  cauliflower  tops,  as  these  are  least  apt  to  cause  flatulence.  Fresh 
young  peas,  mashed  and  strained,  and  fresh,  tender  string-beans  may 
also  be  allowed.  Potatoes,  either  well  baked  or  well  boiled  and 
mashed,  may  be  eaten  in  small  quantities.  All  coarse  and  stalky 
vegetables  are  to  be  avoided.  If  there  is  flatulence,  the  carbohydrates, 
as  well  as  the  fats,  may  be  very  much  lessened  or  omitted  temporarily. 

In  the  more  severe  cases  milk  agrees  better  than  any  other  form  of 
food,  and  should  be  given  in  small  quantities  at  regular  intervals.  As 
a  rule,  it  should  not  be  taken  too  cold.  The  various  modifications  of 
milk  and  other  liquid  foods  that  have  been  mentioned  in  connection 
with  pneumonia  may  be  employed.  In  some  cases,  especially  when 
dropsy  is  severe,  there  is  no  desire  for  food,  and  the  problem  of  feed- 
ing then  becomes  a  difficult  one.  In  these  cases  predigested  foods  of 
various  kinds,  raw  meat-pulp,  as  advised  in  tuberculosis,  and  beef -tea, 
beef-extract,  and  the  like,  may  be  tried. 

SENILE  HEART 

Balfour's  little  book  on  "The  Senile  Heart"  will  prove  a  valuable 
guide  to  the  care  and  management  of  the  aged.  In  his  chapter  relat- 
ing to  diet  he  says:  "Cardiac  troubles  are  always  alarming,  par- 
ticularly in  old  age,  but  much  may  be  done  to  relieve  the  patient  and 
to  prolong  his  life.  Attention  is  to  be  paid  to  the  little  things  of  daily 
life — the  little  things  of  eating,  drinking,  and  doing — that  influence 
the  patient's  comfort  and  gradually  turn  the  scale  of  health  in  his 
33 


514  DIET  IN  DISEASE 

favor.  The  physician 's  regulations  are  often  pitted  against  the  habits 
of  a  lifetime,  and  difficulty  may  be  had  in  securing  acquiescence.  All 
heart  aifections  of  the  old  are  not  necessarily  senile  in  character  or 
origin.  Many  cases  may  be  of  very  long  standing.  Senile  cardiac 
failure  is  essentially  based  upon  imperfect  metabolism.  The  diet  must 
be  regulated  to  suit  the  patient,  and  certain  things  mast  be  considered. 
Most  of  the  patients  are  below  or  at  their  usual  weight.  These  require 
careful  regulation  of  a  normal  dietarj^  to  be  given  presently.  A 
smaller  number  are  over  their  normal  weights,  and  suffer  more  from 
breathlessness  than  the  preceding  class  of  cases.  These  require  to  be 
specially  dieted  and  cared  for,  so  as  to  remove  the  obesity  without 
diminishing  the  cardiac  energy  or  the  strength  of  the  myocardium. 
Lastly,  there  are  those  in  whom  there  is  more  evident  failure  of  the 
myocardium.  There  are  more  evidences  of  dilatation  of  the  heart 
and  of  the  tissues.     Such  cases  require  a  specially  dry  diet." 

Four  Important  Rules, — 1.  An  interval  of  five  hours  should  be 
allowed  to  elapse  between  meals. 

2.  Xo  solid  food  should  be  taken  between  meals. 

3.  All  persons  with  weak  hearts  should  take  their  principal  meal 
in  the  middle  of  the  day. 

4.  Persons  with  weak  hearts  should  take  their  meals  in  as  dry  a 
form  as  possible. 

All  indigestible  food  should  be  avoided.  Especially  to  be  men- 
tioned in  this  class  are  dried,  salted,  or  otherwise  preserved  meats, 
cheese,  pastry,  all  other  foods  in  which  fatty  matter  has  undergone 
prolonged  exposure  to  heat,  and  all  sweets  and  nuts;  owing  to  their 
liability  to  cause  flatulence,  vegetable  food  must  be  chosen  with  care. 
Vegetables  of  the  cabbage  family,  and  carrots,  turnips,  and  parsnips 
are  regarded  with  disfavor  by  Balfour.  Even  potatoes  should  be 
eaten  sparingly.  Fruits  should  not  be  crowded  into  a  meal  as  a 
dessert,  but  may  be  allowed  to  form  part  of  the  meal,  especially  at 
breakfast  or  at  a  midday  dinner. 

No  good  is  to  be  gained  by  attempting  to  enforce  dietetic  rules 
founded  on  the  number  of  grams  of  carbon  or  nitrogen  required  to 
carry  on  the  processes  of  life. 

The  foods  to  be  allowed  persons  with  weak  hearts  are  the  tender 
varieties  of  white  fish,  chicken,  rabbit,  game,  mutton,  or  well-grown 
lamb,  all  of  which  Balfour  gives  in  preference  to  tough  beef.  One 
well-boiled,  ripe,  mealy  potato  may  be  allowed  at  dinner.  Spinach, 
since  it  does  not  cause  flatulence,  is  the  safest  vegetable ;  asparagus- 
tops,  onions,  and  tomatoes  may  be  taken  in  moderation.  Peas,  beans, 
and  other  leguminous  foods,  when  fresh,  young,  and  green,  may  be 
partaken  of  in  moderation. 

Not  more  than  five  ounces  of  fluid,  and  if  possible  less,  should  be 
taken  with  a  meal.  If  water  is  desired  with  the  meals,  it  should  be 
taken  hot  and  sipped  slowly.     If  tea  is  used,  it  should  be  weak — a 


DISEASES  OF  THE  CIRCULATORY  SYSTEM  515 

teaspoonful  of  the  tea  to  five  ounces  of  water,  steeped  for  not  more 
than  three  minutes.  Coffee  may  be  sweetened  to  taste,  and  taken 
black  or  with  cream.  Chocohite  and  cocoa  are  too  rich  for  those  with 
weak  hearts,  but  if  taken  alone  may  occasionally  be  useful. 

Alcohol  should  be  prescribed  only  as  it  is  needed.  So  many  pa- 
tients have  been  accustomed  to  its  use  all  their  lives  that  it  cannot 
be  cut  off  altogether.  For  those  to  whom  alcohol  is  permitted  half 
an  ounce  of  whisky,  brandy,  or  gin  may  be  given  in  three  or  four 
ounces  of  water  twice  a  day,  together  with  their  food ;  or  a  single 
glass  of  sherry  or  port  or  two  glasses  of  any  lighter  wine,  such  as  hock 
or  claret,  each  glass  to  hold  two  fluidounces,  may  be  ordered.  The 
stronger  wines  are  best  omitted,  as  they  are  liable,  if  taken  in  larger 
quantities,  to  give  rise  to  dyspepsia.  Champagne  is.  as  a  rule,  for- 
bidden. Idiosyncrasies  occur  in  regard  to  the  effect  of  wine,  so  that 
the  individual  case  must  be  considered  before  it  is  ordered.  Alcohol 
is  best  given  in  the  form  of  pure  whisky  and  water,  always  in  extreme 
moderation.  As  a  stimulant  for  a  weak  heart,  small  quantities  of 
alcohol  are  frequently  prescribed,  to  be  taken  at  various  times  during 
the  day.  This  is  most  injurious  treatment,  for  althouuh  the  primary 
effect  of  alcohol  is  stimulating,  secondarily  it  is  depressant.  A  better 
plan  is  to  direct  such  a  patient  to  take  two  or  three  sips  of  water,  as 
hot  as  can  be  swallowed,  occasionally'  throughout  the  day.  Apart 
from  that  taken  in  the  food  fifteen  ounces  of  water  a  day  are  all  that 
should  be  allowed,  but  if  severe  thirst  is  complained  of,  a  half  pint 
of  hot  water  may  be  sipped  about  four  hours  after  each  meal  or  only 
after  the  principal  meal.  This  cleanses  the  stomach  and  prepares  it 
for  rest.  Hot  water  quenches  the  thirst  better  than  does  cold.  The 
thirst  is  usually  due  to  a  catarrhal  dyspepsia,  and  soon  disappears 
after  the  diet  has  been  regulated.  The  following  is  Balfour's  dietary, 
which  is  easily  modified : 

"Breakfast  8.30:  One  small  slice  of  dry  toast,  weighing  about 
an  ounce  and  a  half,  with  butter;  one  soft-boiled  or  poached  egg,  or 
half  a  small  haddock,  or  its  equivalent  in  any  other  fresh  white  fish, 
with  from  three  to  five  ounces  of  tea  or  coffee,  wuth  cream  and  sugar. 
If  there  be  any  difficulty  about  the  tea,  it  may  be  replaced  by  a 
similar  quantity  of  infusion  of  cocoa-nibs,  or  milk  and  hot  water,  or 
cream  and  seltzer  water.  Some  prefer  oatmeal  porridge,  with  milk 
or  cream,  and  in  ordinary  circumstances  this  need  not  be  objected 
to,  provided  not  more  than  four  or  five  ounces  of  milk  be  taken,  and 
the  porridge  be  not  more  in  quantity  than  three  or  four  ounces  of 
oatmeal,  well  boiled:  provided,  also,  that  porridge  alone  be  taken,  and 
not  porridge  first,  followed  by  tea,  toast,  etc.,  which  is  destructive  of 
all  comfort,  both  for  stomach  and  heart. 

''The  principal  meal  of  the  day,  whatever  it  is  called,  lunch  or 
dinner,  should  be  taken  about  1.30  or  2  o'clock,  and  may  consist  of 
two  courses,  not  more — fish  and  meat,  or  fish  and  pudding,  or  meat 


516  Z>/£'7'  IX  DISEASE 

and  pudding.  Soups,  pastry,  pickles,  and  cheese  are  absolutely  for- 
bidden. White  tlsh  and  meat  with  short  tibers  are  preferred.  Half 
a  haddock,  or  its  equivalent  in  any  other  white  tish,  boiled  in  milk, 
steamed,  or  broiled,  never  fried;  wing  and  part  of  the  breast  of  a 
chicken,  or  its  equivalent  in  sweetbreads,  tripe,  rabbit,  game,  or  mut- 
ton ;  one  single  potato  or  a  little  spinach.  For  pudding,  any  form  of 
simple  milk  pudding  may  be  taken,  or  about  half  a  pound  of  such 
fruits  as  pears,  apples,  grapes,  etc.,  either  cooked  or  uncooked.  Dur- 
ing this  meal  four  or  five  ounces  of  hot  water  may  be  sipped  if  de- 
sired. 

"From  5  to  6  three  or  four  ounces  of  tea  may  be  taken  if  desired, 
infused,  as  in  the  morning,  not  longer  than  four  minutes,  and  with 
cream  and  sugar  if  wished ;  but  no  solid  food  must  be  taken  with  it 
— not  even  a  morsel  of  cake  or  biscuit.  If  there  be  any  difficulty  about 
the  tea,  four  or  five  ounces  of  hot  water  may  be  substituted  for  it, 
and  if  there  seem  any  need  for  a  stimulant  at  this  time,  a  teaspoonful 
of  Liebig's  extract  of  beef  may  be  stirred  into  it. 

' '  Scupper,  or  the  last  meal  of  the  day,  must  always  be  a  light  meal. 
It  should  be  taken  about  7,  and  may  consist  of  white  fish  and  a  potato, 
or  toast,  with  butter,  or  some  milk  pudding,  or  bread  and  milk,  or 
Eevalenta,  made  with  milk  or  with  Liebig's  extract  of  beef.  At  bed- 
time, four  or  five  ounces  of  hot  water  will  soothe  the  stomach,  pro- 
mote sleep  and  pave  the  way  for  a  comfortable  breakfast  next  morn- 
ing." 

When  there  is  anasarca,  the  following  "dry  diet"  is  recommended 
by  Balfour.     (See  also  Karell  Cure.) 

"Breakfast. — One  single  slice  of  dry  toast,  weighing  about  an  ounce 
and  a  half,  with  no  butter,  but  with  a  single  cup  of  tea  infused  not 
longer  than  four  minvites,  with  cream  and  sugar,  amounting  in  all  to 
not  more  than  four  ounces,  and  nothing  else. 

"Dinner. — Not  more  than  the  lean  of  two  chops,  or  its  equivalent 
in  chicken  or  fish ;  no  vegetables ;  as  much  dry  toast  as  may  be  desired ; 
half  an  ounce  of  brandy,  whisky,  or  Holland  gin,  in  three  ounces  of 
water,  and  nothing  else. 

''Supper.- — As  much  dry  toast  may  be  taken  as  is  desired,  along 
with  half  an  ounce  of  brandy,  whisky,  or  gin  in  three  ounces  of  water; 
and  nothing  more." 

It  is  not  desirable  that  a  patient  in  this  condition  drink  much,  even 
between  meals,  but  if  thirsty,  he  may  be  permitted  to  sip  slowly  three 
or  four  ounces  of  hot  water  about  an  hour  before  each  meal. 

ARTERIOSCLEROSIS 

In  most  eases  of  arteriosclerosis  symptoms  of  senile  heart  occur  at 
the  same  time,  and  the  same  general  principles  may  be  followed  as 
were  directed  for  that  condition.  The  French  particularly  advocate 
a  milk  diet  in  the  treatment  of  arteriosclerosis,  and  where  there  are 


DISEASES  OF  THE  CIRCULATORY  SYSTEM  517 

headaches,  insomnia,  and  other  untoward  symptoms,  an  absolute  milk 
diet  may  be  used  with  advantage.  xVs  soon  as  the  symptoms  dis- 
appear a  mixed  diet  may  be  substituted.  (See  Milk  Cure  for  methods 
of  giving  milk.)  Mineral  water  may  be  prescribed,  or  trips  may  be 
made  annually  to  mineral  springs.  Whenever  possible  alcohol  should 
be  prohibited.  A  diet  similar  to  that  used  in  high  blood-pressure  will 
be  found  effective  in  many  cases. 

HIGH  BLOOD-PRESSURE 

Patients  with  high  blood-pressure  may  generally  be  dieted  along 
the  same  lines  as  cases  of  interstitial  nephritis  and  in  some  cases  very 
good  results  may  be  obtained  by  the  temporary  use  of  a  non-nitrogen- 
ous diet  followed  by  a  diet  low  in  nitrogen  and  particularly  those 
from  the  vegetable  kingdom.  If  the  patient's  condition  permits  he 
should  be  given  the  benefit  of  free  catharsis,  and  if  there  is  no  heart 
involvement  should  be  encouraged  to  drink  water  freely  with  the  view 
of  eliminating  such  toxic  substances  as  may  be  present  and  causing 
the  increased  pressure,  and  the  treatment  is  also  enhanced  by  mild 
sweats  in  the  cases  in  which  the  condition  is  not  good,  and  by  more 
profuse  ones  in  the  stronger  patients.  Foods  that  are  eliminated 
through  the  kidneys  should  be  omitted  or  limited  as  far  as  possible. 
Dale  and  Dixon  and  Barger  and  Malpole  found  that  decomposing 
meat  contains  a  substance  which  increases  the  blood-pressure  and  that 
this  substance  may  be  formed  by  the  action  of  intestinal  bacteria  on 
tyrosin.  Inasmuch  as  tyrosin  is  present  in  all  proteins  except  gelatin, 
a  meat  free  diet  has  been  pretty  generally  instituted.  In  some  in- 
stances cooked  eggs  have  been  added  to  the  dietary. 

Non-nitrogenous  diets  or  those  in  which  the  nitrogen  content  is 
reduced  to  a  minimum  may  be  made  up  of  fruit  juices,  such  as  orange, 
lemon  and  grape  juices  and  the  food  value  may  be  greatly  enhanced 
by  the  addition  of  sugar.  Fruits  may  be  eaten  and  preserves  added; 
perfectly  plain  .sugar  candy.  A  sufficient  amount  of  crackers  or 
zwieback  or  toast  may  be  allowed  together  with  rice,  cream  of  wheat, 
hominy,  cornstarch  pudding  and  tapioca  pudding,  made  without  eggs. 

Low  nitrogen  diets  may  be  made  up  of  any  sort  of  cereals — oatmeal, 
cream  of  wheat,  cornmeal  mush,  shredded  wheat  biscuit,  and  the 
various  bread  stuffs.  Vegetable  soups  or  purees  of  beans  or  peas, 
but  these  latter  in  rather  limited  quantities  and  green  vegetables. 
Gelatin  jellies  and  calf's  foot  jelly  may  be  added  and  if  it  is  desired 
to  increase  the  amount  of  nitrogen  eggs  and  milk  may  be  added  to 
the  diet. 

Additional  suggestions  for  a  non-nitrogenous  diet  will  be  found 
under  the  heading  of  Nephritis. 

ANEURYSM 
In  most  cases  of  aneurysm  that  are  proving  troublesome  the  treat- 
ment consists  of  rest,  a  restricted  diet  with  a  limited  amount  of  fluid, 


518  DIET  ly  DISEASE 

together  with  potassium  iodid."  From  ten  to  twenty  grains  of  the 
iodid  three  times  a  day  are  sufficient. 

Certain  cases  of  aneurysm  may  be  relieved  by  rigorous  dieting. 
The  saccular  forms,  and  especially  cases  of  aortic  aneurysm  with 
small  openings,  are  most  apt  to  improve  under  this  treatment.  Diet- 
ing is  also  helpful,  it  is  said,  in  traumatic  aneurysm.  Tuffnell,  of 
Dublin,  advised  the  following  diet: 

Breakfast. — Two  ounces  of  bread  with  a  little  butter  and  2  ounces 
of  milk. 

Dinner. — From  2  to  3  ounces  of  meat  without  salt,  and  4  ounces  of 
milk  or  claret. 

Supper. — The  same  as  breakfast. 

Absolute  physical  and  mental  rest  must  be  secured  for  the  patient, 
and  a  competent  nurse  who  will  see  that  the  diet  is  strictly  adhered  to 
is  essential.  Thirst  may  be  relieved  by  small  quantities  of  acidulated 
drinks  or  by  sips  of  hot  water.  Potassium  iodid  may  be  prescribed, 
as  may  also  morphin.  Few  patients,  however,  are  willing  to  undergo 
the  suffering  that  such  treatment  entails,  and  not  many  will  persist  in 
it  for  more  than  several  weeks.  Tuffnell  advised  that  it  is  to  be 
followed  for  several  months,  and  he  and  others  report  cures  in  certain 
cases.  The  anemia  that  follows  may  be  extreme,  and  may  leave  the 
patient  in  a  serious  condition. 

Broadbent  advises  rest  and  small,  equal-sized  meals,  taken  at  regular 
intervals.  The  meals  must  be  concentrated,  and  bulky  substances, 
such  as  rice,  potatoes,  and  bread,  are  to  be  excluded  from  the  dieta^s^ 
The  amount  of  water  taken  in  twenty-four  hours  should  not  exceed 
forty  ounces,  and  as  much  less  as  possible  is  to  be  taken.  Twenty- 
four  ounces  he  places  as  the  minimum. 

The  object  of  the  treatment  is  to  produce  the  slow  circulation  of 
a  condensed  blood  in  the  hope  that  fibrin  may  be  formed  in  the  sac. 
Burney  Yeo  does  not  favor  such  severe  dieting. 

When  the  case  is  not  a  suitable  one  and  is  not  giving  especial 
trouble,  it  is  probably  best  to  recommend  a  quiet  life  and  a  simple 
diet,  avoiding  indigestible  articles  of  food  and  those  that  cause  flatu- 
lence. As  Osier  has  said,  the  medical  profession  has  furnished 
numerous  examples  of  men  with  aortic  aneurysm  living  for  consider- 
able periods  and  doing  good  work.  Of  these  the  late  Hilton  Fagge 
was  a  notable  example. 

ANGINA  PECTORIS 

In  this  disease  diet  is  of  the  greatest  importance.  The  majority 
of  cases  occur  in  "large  eaters,"  and,  as  Osier  says,  there  is  "death 
in  the  pot."  As  a  rule  these  patients  realize  that  overeating  is  harm- 
ful to  them. 

The  meals  should  be  small  and  easily  digestible,  and  all  rich,  highly 
seasoned  food,  as  well  as  anything  that  causes  fermentation,  should 


DISEASES  OF  THE  CIRCULATORY  SYSTEM  519 

be  carefully  avoided.  Flatulence  is  a  symptom  that  must,  so  far  as 
possible,  be  avoided,  for  as  soou  as  the  stomach  becomes  distended 
distress  follows  that  may  produce  an  attack.  The  evening  meal  should 
be  small,  and  eating  late  at  night  should  be  prohibited. 

If  the  patient  is,  in  addition,  the  subject  of  gout  or  glycosuria,  his 
diet  must  be  regulated  accordmgly.  The  diet  suitable  for  various 
cases  differs  widely,  and  personal  idiosyncrasy  must  always  be  taken 
into  account. 

In  his  lectures  on  angina  Osier  calls  to  mind  that  Dr.  Smollet,  in 
Humphrey  Clinker,  makes  one  of  his  characters,  Matt  Bramble,  say: 
''For  my  own  part,  I  have  had  a  hospital  these  fourteen  j-ears  within 
myself,  and  studied  my  own  case  with  most  painful  attention,  con- 
sequently may  be  supposed  to  know  something  of  the  matter."  An 
intelligent  patient  should  know  what  food  does  and  what  does  not 
cause  flatulence.  Flatulence  is  most  apt  to  occur  in  fat  flabby  pa- 
tients and  in  those  with  weak  hearts  and  arteriosclerosis.  Hot  water 
taken  half  an  hour  before  meals  may  be  useful. 

In  those  with  whom  the  drinking  of  stimulants  is  a  life-long  habit 
alcohol  may  be  allowed,  best  in  the  form  of  hot  toddy  at  bedtime. 
To  quote  Osier  again  this  may  prevent  the  flatulence  that  is  apt  to 
come  on  during  the  early  morning  hours. 

ANEMIA 

Acute  Postheimorrhagic  AnemSa. — The  reader  is  referred  to  the 
section  on  Diet  after  Operations  for  suggestions  as  to  the  diet  in  this 
disorder.  In  the  case  of  the  smaller  hemorrhages,  which  are  rapidly 
recovered  from,  the  usual  diet  may  be  followed.  In  the  more  severe 
forms,  special  care  may  be  required.  If  the  anemia  that  follows  a 
severe  hemorrhage  becomes  chronic,  the  patient  is  to  be  managed  the 
same  as  in  chronic  secondary  anemia.  If  much  blood  has  been  lost, 
fluid  should  be  supplied  to  the  body  in  the  form  of  normal  salt  solu- 
tion, by  transfusion  into  a  vein,  subcutaneously,  by  the  rectum,  or  by 
the  mouth,  according  to  the  condition  of  the  patient.  In  most  cases 
the  fluid  part  of  the  blood  is  rapidly  replaced.  If  the  hemorrhage  has 
been  from  the  stomach  or  bowel,  special  management,  as  detailed  under 
their  respective  headings,  is  necessary. 

If  the  patient  is  very  weak,  cold  milk  is  usually  the  most  acceptable 
form  of  food.  Hot  milk  is  preferred  by  some,  and  is  best  for  many 
cases.  Fresh  beef-juice  and  weak  beef-tea  are  valuable,  as  is  also 
albumin-water.  As  soon  as  the  patient  is  able  to  eat,  a  diet  containing 
considerable  protein  and  the  fresh  green  vegetables  should  be  ad- 
ministered, as  well  as  milk,  eggs,  rare  or  raw  meat,  with  spinach, 
asparagus-tips,  apples,  strawberries,  and  other  fresh  fruits  and  vegeta- 
bles. 

Indigestible  articles  should  be  avoided,  and  strong  tea,  coffee,  and 


520  DIET  ly  DISEASE 

the  much  concentrated  beef-teas  should  not  be  taken,  especially  in  the 
acute  stages. 

According  to  the  meager  experiments  and  observations  that  have 
been  made  on  this  subject,  the  metabolic  processes  of  the  body  are 
either  about  normal  or  similar  to  those  going  on  in  a  condition  of 
hunger.     Iron  in  some  form  is  advisable  in  the  severer  cases. 

Chronic  Secondary  Anemia. — Efforts  should  be  made  to  locate 
and  remove  the  cause.  The  diet  should  be  about  the  same  as  that 
recommended  for  chlorosis.  Fresh  food,  milk,  eggs,  meats,  green 
vegetables,  and  fresh  fruits  are  the  most  important  articles  of  diet. 
Fresh  air  and  sufficient  rest  are  also  essential. 

Pernicious  Anemia. — In  spite  of  the  grave  anemia  the  body  fat 
and  muscles  often  remain  for  a  considerable  time  but  little  diminished 
in  size.  The  blood  destruction,  however,  is  progressive,  and  tends  to 
a  fatal  ending.  Rest,  removal  to  a  different  climate,  fresh  air,  and 
attention  to  the  diet  may  in  some  cases  prolong  life.  Nevertheless  the 
tendency  of  the  disease  is  to  become  progressively  worse. 

Owing  to  the  anorexia,  vomiting,  and  diarrhea  that  are  apt  to  be 
present,  the  diet  is  a  matter  of  importance.  Coupland  and  Hunter 
claim  that  a  carbohydrate  diet  is  better  borne  than  one  composed 
largely  of  proteins.  As  the  result  of  experiment.  Hunter  has  been  led 
to  believe  that  intestinal  putrefaction  occurs  less  often  on  a  milk  and 
carbohydrate  diet. 

Predigested  foods,  prepared  infants'  or  invalids'  foods,  raw  meat- 
juice,  and  similar  articles  of  food  may  be  allowed.  Small  .quantities 
of  alcohol  may  also  be  prescribed. 

During  recent  years  the  bone-marrow  of  long  bones  of  animals  has 
been  recommended  highly  in  cases  of  pernicious  anemia.  The  marrow 
is  eaten  raw,  in  doses  of  from  one  to  three  tablespoonfuls  twice  daily. 
The  authors  have  obtained  good  results  in  several  cases  from  this  form 
of  treatment. 

Barker  and  Sprunt  have  made  some  observations  on  the  Addison- 
Biermer  type  of  pernicious  anemia,  and  in  addition  to  the  other  thera- 
peutic measures  they  suggest  a  rest  cure,  beginning  on  a  milk  diet, 
two  and  a  half  ounces  everj^  two  hours  from  7  a.  m.  to  9  p.  m.,  the 
two  hourly  quantity  being  increased  each  day  until  by  the  sixth  day 
the  patient  is  receiving  about  three  liters.  On  the  seventh  day  a 
small  piece  of  bread  and  a  little  jam  is  allowed  at  breakfast  and  at 
midday  a  trayful  of  easily  digested  foods.  Taking  the  milk  is  insisted 
upon,  even  if  there  is  some  vomiting  it  is  continued  at  regular  inter- 
vals. The  portions  of  the  solid  foods  are  at  first  not  large,  but  during 
the  next  few  days  are  rapidly  increased  until  the  patient  is  on  an 
abundant  diet,  rich  in  protein,  and  if  he  is  thin,  in  carbohydrates  and 
fat  also. 

At  this  time  a  raw  egg  with  a  little  orange  juice  is  given  after  each 
meal  and  later  on  two  eggs  after  each  meal  may  be  given.     Extra 


DISEASES  OF  THE  CIRCULATORY  SYSTEM  521 

milk  is  given  as  far  as  possible,  with  meals  rather  than  between  them. 
With  this  method  a  patient  may  within  two  or  three  weeks  be  induced 
to  take  six  eg'gs,  a  quart  and  a  half  of  milk  and  a  pint  of  cream  each 
day,  in  addition  to  three  full  meals,  a  dietary  containing  from  4,000 
to  5,000  calories.  When  the  jiatient  is  obese  a  large  amount  of  pro- 
tein, meat  ajid  eggs,  is  given,  together  with  green  vegetables  in  puree 
form  and  stewed  fruits.  The  carbohydrates  and  fats  are  low  and  the 
total  value  per  day  of  the  food  does  not  exceed  1,000  or  1,500  calories. 
JMore  intelligent  patients  are  taught  to  figure  out  the  number  of  cal- 
ories in  the  diet  and  keep  a  food  chart,  which  is  easily  done  by  using 
Locke's  tables  (reprinted  elsewhere  in  this  volume). 

CHLOROSIS 

The  diet  for  chlorotic  patients  is  not  generally  understood,  and 
therefore  requires  especial  study. 

In  chlorosis  no  changes  occur  in  either  fat  or  muscles.  Some  pa- 
tients are  fat  while  others  are  thin,  this  depending  for  the  most  part 
on  accidental  circumstances,  and  bearing  only  an  indirect  relation  to 
the  anemia.  The  thin  patients  are  usually  those  individuals  who  are 
of  that  habit ;  those  who  have  co-existing  disease  of  the  stomach ;  those 
who  take  too  little  food  and  who  are,  in  consequence,  suffering  from 
malnutrition;  or  lastly,  those  who  must  undergo  considerable  bodily 
exertion,  usually  in  getting  their  livelihood. 

The  fat  patients  and  those  who  are  often  edematous  looking  are 
individuals  who  are  either  fat  by  nature  or  who  are  receiving  too  much 
milk  or  other  fluid  with  their  diet. 

Under  a  proper  diet  no  change  in  the  weight  may  occur ;  or  in  the 
case  of  the  fat,  edematous-looking  patients,  there  may  be  a  loss  in 
weight  while  the  anemia  is  improving,  or  if  the  patient  has  been  taking 
too  little  nourishment  or  is  doing  too  much  work  and  is  thin  in  con- 
sequence, there  may  be  a  gain  in  weight.  The  metabolic  processes,  so 
far  as  is  known,  are  the  same  as  in  health.  Owing  to  the  lowered 
liemoglobin  value  of  the  blood,  the  patient  is  not  able  to  exert  herself 
much  without  producing  great  fatigue. 

In  the  treatment  of  the  chlorotic  patient  three  things  are  important : 
iron,  sufficient  food  at  proper  intervals,  and  rest. 

Regarding  the  diet,  the  quality  and  the  quantity  of  the  food  may  be 
the  same  as  in  healthy  individuals.  The  meals  should  be  given  at 
regular  intervals,  not  too  widely  separated — usually  not  more  than 
three  hours  apart.  In  consequence  of  the  shorter  interval  and  because 
the  patient's  desire  for  food  is  apt  to  be  lowered,  the  meals  should  be 
small.  The  appetite  is  capricious,  and  while  the  regular  meals  may  be 
left  untouched,  such  undesirable  articles  as  pickles  and  sweets  may 
be  greedily  devoured  in  the  intervals.  This  tendency  should  be  con- 
trolled and  nothing  allowed  between  the  meals.  Von  Noorden  recom- 
mends five  meals  daily — at  8,  10.30,  1,  4.30,  and  7  or  7.30.     This  same 


522  DIET  IN  DISEASE 

observer  also  insists  on  the  value  of  taking  an  abundance  of  protein 
food  at  breakfast,  giving  as  his  reason  that  protein  is  the  only  food 
(alcohol  not  being  considered)  that  is  ready  for  use  in  the  body 
shortly  after  ingestion.  Carbohydrates  for  the  most  part  go  first  to 
the  liver,  and  fats  are  too  slowly  absorbed.  The  patient  who  takes  the 
customary  continental  breakfast  of  cott'ee  and  rolls  has  a  long  wait 
before  the  cells  receive  adequate  nourishment.  The  kind  of  protein 
food  is  of  little  importance,  and  may  be  either  meat  or  eggs ;  meat  is, 
however,  especially  recommended,  and  should  be  taken  regularly  for 
breakfast  in  a  definite  quantity. 

In  general  the  diet  should  also  contain  sufficient  protein,  and  von 
Noorden  advises  the  use  of  such  preparations  as  somatose,  nutrose, 
protogen,  or  eucasin,  when  necessary  to  increase  the  quantity  of 
protein. 

Milk  is  generally  prescribed  in  too  large  quantities.  This  should 
be  avoided  where  the  appetite  is  small,  as  a  glass  of  milk  in  these 
cases  generally  checks  any  further  desire  for  food.  It  is  also  to  be 
avoided  in  those  cases  in  which  the  appetite  is  fair  but  the  patient 
shows  a  decided  tendency  to  take  on  fat  or  to  become  somewhat 
edematous  looking.  In  these  individuals  the  cells  retain  too  much 
water.  When  there  is  atony  of  the  stomach,  water  is  to  be  taken  in 
small  quantities.  Milk  is  to  be  used  by  patients  who  are  thin  and 
where  there  has  been  a  preexisting  malnutrition.  Milk  and  cream 
mixed  is  of  great  value. 

Fresh  fruit  and  vegetables,  particularly  the  green  vegetables,  are 
of  especial  value  and  may  be  partaken  of  freely.  All  kinds  of  fresh 
fruit  in  season  are  to  be  recommended,  avoiding  small-seeded  berries 
where  there  is  irritability  of  the  stomach.  If  fresh  fruits  can  not  be 
obtained,  properly  prepared,  evaporated  fruit  may  be  eaten  and 
helps  to  regulate  the  bowels.  Fresh  fruit  and  vegetables  do  not,  as  a 
rule,  cause  the  disturbance  of  the  stomach  so  often  attributed  to  them. 
In  cases  of  ulcer  of  the  stomach  and  often  in  other  gastric  disorders 
they  must,  however,  be  avoided.  When  fruit  disagrees,  it  usually 
causes  pain  or  fiatulence.  Von  Noorden  recommends  that  it  be  taken 
in  the  afternoon  or  with  the  meals.  For  Americans  some  fruit  at 
breakfast  is  of  value,  but  it  should  not  be  eaten  to  the  exclusion  of  the 
more  important  meat. 

In  the  ordinary  case  of  chlorosis  alcohol  may  be  dispensed  with. 
If  given,  it  should  be  done  guardedly,  as  patients  become  accustomed 
to  taking  it  to  relieve  the  feeling  of  weakness  and  faintness.  A  small 
quantity  of  port,  sherry,  or  one  of  the  other  stronger  wines  may  be 
allowed  as  an  appetizer  half  an  hour  before  the  midday  meal.  In 
the  thin  or  overworked  a  good  beer  may  be  taken  in  moderation  with 
the  principal  meals.  Red  wine,  which  is  often  recommended,  is  of 
no  particular  value. 


DISEASES  OF  THE  CIRCVLATORY  SYSTEM  523 

Von  Noordcu  gives  the  following  suggestions  for  the  selection  of 
the  diet  in  chlorosis : 

The  breakfast  may  be  taken  in  bed,  or  the  patient  allowed  to  rest 
on  a  lounge  for  an  hour  after  the  meal.  IMany  patients  will  go  to 
sleep,  and  this  should  be  encouraged  by  darkening  the  room  and 
avoiding  disturbing  noises.  Two  or  three  ounces  or  more  of  meat 
should  be  taken,  with  as  little  other  food  as  possible.  A  slice  or  two 
of  toast  or  a  piece  of  unsweetened  zwieback  may  be  given,  together 
with  a  sixiall  (juantity  of  tea  or  coffee  with  but  little  sugar  or  cream. 

The  second  breakfast  consists  of  two  eggs,  prepared  in  whatever 
way  the  patient  prefers,  with  toast  and  butter  and  a  glass  of  milk. 
A  tablespoonful  of  cognac  may  be  allowed  in  the  milk  or  a  small  glass 
of  ^Madeira,  sherry,  or  port  may  be  given. 

The  midday  meal  should  be  preceded  by  a  complete  rest  for  half 
an  hour.  The  patient  may  eat  whatever  she  desires,  but  meat  should 
always  be  eaten  first.  If  the  appetite  is  poor,  soup  should  not  be 
allowed,  or  should  be  given  after  the  meat  has  been  taken.  Thirst  is 
generally  marked  at  this  time,  but  fluids  should  not  be  taken  until  the 
end  of  the  meal,  so  as  not  to  disturb  the  appetite.  After  eating  the 
patient  should  rest  from  one-half  to  three-quarters  of  an  hour.  If 
there  should  be  pain  or  discomfort  in  the  stomach,  hot  applications 
may  be  made  to  the  abdomen. 

In  the  afternoon,  cooked  or  raw  fruit  with  bread  or  zwieback,  or,  if 
fruit  is  forbidden,  tea  or  cocoa  and  toast  may  be  given.  If  there  is  no 
tendency  to  superaciclity  of  the  stomach,  bread  and  honey  or  fruit- 
jelly  may  be  allowed.  A  glass  of  milk  or  milk  and  cream  should  be 
taken  after  the  meal. 

The  evening  supper  should  be  as  simple  and  as  unirritating  as 
possible.  Four  times  a  week  a  thick  soup  or  gruel  of  oatmeal,  barley, 
rice,  or  tapioca  may  be  given,  with  meat-broth  and  butter  or  with  milk 
and  butter.  If  desired,  eggs  or  other  light  foods  may  be  given  instead. 
Stewed  fiiiit  may  also  be  allowed  several  times  a  week.  If  the  hunger 
is  not  satisfied  cold  meat  may  be  permitted  in  addition.  On  other 
days  eggs,  meat,  or  fish  may  form  the  principal  part  of  the  evening 
meal.  A  glass  of  well-brewed  beer  or  a  glass  of  milk  may  be  given  at 
bedtime,  which  should  never  be  later  than  10  o'clock. 

The  diet  in  emaciated  patients,  since  there  is  apt  to  be  either  loss  of 
appetite  or  disease  of  the  stomach,  is  sometimes  difficult  to  regulate. 
A  change  of  cooking  may  be  beneficial.  Von  Noorden  allows  100 
grams  of  protein  daily  with  butter,  cream,  or  cod-liver  oil.  A  moder- 
ate amount  of  carbohydrates  may  be  allowed,  but  not  to  the  exclusion 
of  other  food.  ^lilk  may  be  given  an  hour  before  rising  in  the  morn- 
ing, and  alcohol  may  often  be  used  with  advantage. 

When  the  patients  show  a  tendency  to  become  fat  and  apparently 
edematous,  the  diet  must  be  made  as  dry  as  possible — somewhat  similar 


524  DIET  IN  DISEASE 

to  the  dry  diets  recommended  in  certain  heart  diseases.  Sweating- 
may  also  be  induced  in  order  to  reduce  the  amount  of  fluid  in  the 
tissues.  Rapid  recovery  sometimes  follows  this  method  of  treating 
flabby  chlorotie  patients.  When  there  is  disease  of  the  stomach,  the 
diet  is  regulated  accordingly.  Constipation  is  to  be  relieved  by  suit- 
able diet,  or,  if  necessary,  drugs  may  be  resorted  to. 

LEUKEMIA 

The  diet  in  leukemia  should  be  a  general  mixed  one,  but  should 
contain  as  much  protein  as  possible.  The  choice  of  foods  will  depend 
largely  on  the  condition  of  the  stomach  and  intestines.  In  leukemia 
the  metabolic  processes  are  heightened. 

During  the  early  stages,  however,  they  remain  about  normal.  As 
the  disease  progresses  there  is  said  to  be  an  increase  in  the  excretion 
of  nitrogen.  This  calls  for  an  extra  amount  of  protein  food  to  make 
up  the  deficiency.  This  may,  however,  be  a  difficult  matter,  owing 
to  the  liability  to  cause  disturbance  of  the  stomach  and  intestines. 
The  diet  should  be  arranged  so  as  to  contain  the  largest  possible 
amount  of  easily  assimilated  protein  material.  Sugars,  starches,  and 
fats  should  be  given  sparingly,  since  their  digestion  requires  too 
much  time  before  they  can  be  utilized  by  the  tissues. 

Milk  and  the  milk  derivatives,  such  as  buttermilk  and  kumiss,  eggs, 
and  the  more  easily  digested  meats  should  form  the  bulk  of  the  dietary. 
"When  they  agree,  bread,  toast,  and  well-cooked  cereals  may  be  taken 
in  moderation.  Of  the  vegetables,  spinach,  asparagus-tips,  cauliflower 
tops,  and  young  green  vegetables  are  to  be  preferred.  The  selection 
of  the  diet  will  often  be  governed  by  complicating  bowel  disorders. 

Alcohol  may  be  allowed  as  needed,  and  the  desires  of  the  patient 
should  be  consulted  as  far  as  possible  regarding  the  form  in  which  it 
is  to  be  taken. 

PURPURA  HAEMORRHAGICA 

Litten  gives  the  following  suggestions  as  to  the  diet  in  this  disease: 
The  food  must  be  bland  and  should  be  given  cool.  Coffee,  strong  tea, 
and  spirits  should  be  strictly  forbidden.  Alcohol  may  be  allowed 
when  there  is  collapse.  ]\Iilk  and  somatose  in  milk  are  suggested  as 
the  most  valuable  foods,  but  the  diet  may  be  arranged  as  in  any  acute 
febrile  condition.  A  diet  containing  a  considerable  amount  of  gelatin 
has  been  recommended.  Other  authors  suggest  the  use  of  an  anti- 
scorbutic diet,  although  no  good  reason  exists  for  this,  except  that 
some  of  the  so-called  cases  of  purpura  may  in  reality  be  scurvy  or 
something  akin  to  it. 

HEMOPHILIA 

A  general  diet,  of  which  milk,  however,  forms  a  considerable  part, 
is  suggested  by  Litten.  who  also  recommends  the  use  of  the  fresh 
green  vegetables  and  salads.     Fresh  fruit  and  lemonade  may  be  used 


DIET  ly  DISEASES  OF  THE  OEMTO-URiyARY  SYSTEM  525 

freely.  Coarse  food,  especially  the  coarser  vegetables,  should  be 
avoided.  Calcium  containing  foods  have  been  thought  to  be  of  use. 
For  Calcium  content  of  foods  see  Oxaluria. 

DIET  IN  DISEASES  OF  THE  GENITO-URINARY  SYSTEM 

Urine  and  Food. — The  urine  bears  a  direct  relation  to  the  quality 
and  quantity  of  the  food  ingested,  as  well  as  to  the  quantity  of  fluid 
taken  and  the  amount  of  work  done  by  the  individual.  Many  varia- 
tions in  the  urine  occur  that  are  due  to  food  or  drink  and  that  are 
normal.  "When  the  kidneys  are  diseased  improper  food  may  bring 
on  dangerous  or  even  fatal  conditions.  After  a  large  meal  of  any 
kind  the  urine  becomes  alkaline  temporarily. 

The  ingestion  of  large  quantities  of  fluid  and  the  eating  of  juicy 
fruits  or  vegetables  tend  to  dilute  the  urine,  and  to  render  it  less  acid 
and  its  solid  contents  relatively  less.  With  milk  diet  the  urine  be- 
comes acid  and  indican  may  be  found  in  it.  A  concentrated  dry  diet 
decreases  the  amount  of  urine,  increases  the  specific  gravity,  and 
makes  the  reaction  more  acid.  Animal  food  and  the  more  nitrogenous 
vegetables  increase  the  amount  of  nitrogen  compounds  and  the  acidity 
of  the  urine.  Vegetables  increase  the  carbonates  and  the  earthy  salts 
of  the  urine.  A  purely  vegetable  diet  renders  the  urine  alkaline. 
Thompson  states  that  Cantani  maintains  that  large  quantities  of 
vegetable  acids  will  render  the  urine  alkaline. 

Lipuria,  according  to  Halliburton,  may  be  caused  by  a  diet  rich 
in  fat,  even  when  the  kidneys  are  normal. 

Phosphaturia  is  believed  to  be  increased  by  the  use  of  potatoes, 
fruit,  and  all  fresh  green  vegetables,  and  to  be  decreased  by  adher- 
ing to  a  diet  from  which  these  have  been  eliminated.  Such  a  diet 
would  include  meat,  eggs,  milk,  cheese,  cereals,  and  the  legumes. 

Oxaluria. — This  is  a  term  applied  to  a  condition  where  calcium 
oxalate  crystals  are  deposited  in  the  urine.  The  normal  limit  of 
oxalates  excreted  in  twenty-four  hours  has  been  placed  by  Senator  at 
about  20  mgm.  Whilst  oxaluria  may  be  regarded  as  an  expression 
of  a  disturbance  of  metabolism,  the  quantity  of  oxalates  excreted  is 
only  one  factor  to  be  considered.  The  second  part  of  the  question 
consists  in  the  power  of  the  urine  to  hold  the  otherwise  insoluble 
calcium  oxalate  in  solution.  The  solubility  of  this  salt  depends  upon 
the  acid  phosphates,  especially  upon  the  quantity  of  magnesium  salt 
present,  and  naturally  it  is  influenced  by  the  amount  of  calcium  ex- 
creted in  the  urine.  A  urine  containing  a  large  quantity  of  mag- 
nesium phosphate  and  a  small  quantity  of  calcium  salts  will  hold  more 
calcium  oxalate  in  solution  than  urine  containing  the  reverse. 

Oxaluria  is  accompanied  by  a  number  of  nervous  and  gastric  dis- 
turbances, generally  spoken  of  as  either  neurasthenia  or  nervous 
dyspepsia.     The  exact  relation  of  these  symptoms  to  oxaluria  is  not 


526  DIET  IN  DISEASE 

always  clear,  and  clinically  the  symptoms  which  arise  from  the  pres- 
ence of  oxalate  crystals  irritating  the  urinary  passages  and  the  danger 
of  formation  of  stone,  either  in  the  kidney  or  bladder,  are  of  much 
more  importance. 

Previous  to  the  experiments  of  G.  Klemperer  and  Tritschler,  it  was 
not  certain  whether  the  oxalic  acid  excreted  was  derived  from  the 
food  or  from  metabolic  processes.  It  is  beyond  question,  however, 
that  foods  containing  oxalic  acid  when  taken  into  the  body  increase 
the  amount  of  calcium  oxalate  in  the  urine.  If  oxalic  acid  is  neu- 
tralized with  carbonate  of  soda  and  given  to  an  individual,  but  a 
small  part  of  it  can  be  recovered  in  the  urine  or  stools,  the  greater 
part  of  it  disappears.  Of  the  oxalic  acid  taken  in  the  food  materials, 
as  in  spinach,  about  20  per  cent,  can  be  recovered  in  the  urine  and 
stools,  most  of  this  in  the  urine,  whilst  80  per  cent,  of  it  disappears. 
This  disappearance  is  caused  by  bacterial  and  chemical  action  in  the 
intestines,  changing  the  oxalates  into  other  compounds.  Oxalic  acid 
is  also  destroyed  in  the  blood,  whilst  calcium  oxalate  is  not.  When 
foods  containing  oxalic  acid  enter  the  stomach  a  part  of  it  is  dissolved 
in  the  gastric  juice  and  about  10  per  cent,  absorbed.  In  the  blood 
and  lymph  circulation  this  is  changed  into  calcium  oxalate  and  on  the 
following  day  it  is  excreted  in  the  urine. 

Besides  being  taken  into  the  body  directly  as  oxalic  acid,  certain 
food  substances  are  changed  in  the  processes  of  metabolism  into  oxalic 
acid  or  oxalates  and  so  increase  the  quantity  excreted  in  the  urine. 
Substances  containing  many  nuclei,  as  glands  and  also  muscle,  may 
be  so  changed  that  fat,  carbohydrates,  and  pure  albumin  are  not,  but 
Klemperer  regards  gelatin  as  a  frequent  source  of  oxalates.  Uric 
acid  is  not  changed  into  oxalic  acid  in  the  body,  but  it  is  possible 
that  fermentation  in  the  bowel  may  lead  to  the  formation  of  oxalic 
acid. 

Furthermore,  oxalates  are  apparently  formed  in  the  body  apart 
from  the  food  supply.  Liithje  found  calcium  oxalate  in  the  urine  of 
a  fasting  dog,  and  there  is  a  transient  increase  in  the  amount  of  oxalic 
acid  excreted  during  the  stage  of  resolution  of  penumonia.  Experi- 
mentally Rosenqvist  has  produced  oxaluria  by  the  destruction  of  the 
red  blood-cells  by  the  injection  of  pyrogallic  acid.  Klemperer  is  of 
the  opinion  that  part  of  the  oxalic  acid  excreted  comes  from  the 
metabolism  of  the  resorbed  bile,  as  in  the  bowel  glycocoll  is  formed 
from  glycocholic  acid. 

The  arrangement  of  a  diet  to  cure  or  to  prevent  oxaluria  becomes 
clear  upon  a  consideration  of  the  foregoing  statements.  In  the  first 
place,  the  amount  of  oxalic  acid  and  oxalic-acid-forming  foods  taken 
into  the  body  must  be  diminished  or  cut  off  altogether.  This  means 
forbidding  fruits  and  vegetables  containing  large  amounts  of  oxalic 
acid,  chief  of  which  are  spinach,  sorrel,  rhubarb,  and  cabbage.  Gela- 
tin and  meats  containing  many  nuclei,  as  glands,  should  also  be  for- 


DIET  IX  DISEASES  OF  THE  GENITO-URiyARY  SYSTEM 


527 


bidden, 
foods : 


The  following  tables  give  the  oxalic-acid  content  of  various 


Oxalio   Content   of    Various   Foods   Re-arranged   after   Esbach's   determinations, 

as  quoted  by  Minkoivski. 


T„  TAfiA «™o  Contained  oxalic 

In  1000  grams.  ^^i^  i,^  ^^.^^^^ 

Cocoa     4.5 

Black   Tea    3.7 

Sorrel    3.6 

Pepper     3.2 

Spinach     3.2 

Rhubarb      2.4 

Gooseberries     0.13 

Bread   crust     0.13 

Plums    0.12 

Figs    (dried)    1.0 

Chocolate 0.9 

Chicory      0.7 

Potatoes    0.4 

Beets      0.4 

Beans     0.3 

Green  Beans    0.2 

Coffee    0.1 

Endives     0.1 

Various  flours   0-0.17 

Strawberries     O.OG 

Tomatoes     0.05 

Bread     0.047 


In  1000  grams.  ""^"^I^^ 

Carrots    0.03 

Rose   Cabbage    0.02 

Celery    0.02 

Cress     Traces 

Apples    " 

Rice     Doubtful 

Lentils      

Peas    

Green  Peas   

Turnips    

Asparagus      

Lettuce     

White  Cabbage  and  cauliflower 

Cucumbers     

Mushrooms    

Onions    

Leeks    

Pears    

Apricots     

Peaches    

Grapes    

]Melons    


Oxalic-acid  Content  of  some  Animal  Foods   (Cipollina) . 
In  1000  grams.  Oxalic  acid  in  grams. 

Thymus     0.0115-0.0254 

Liver      0.0064-0.0113 

Spleen      0.018 

Lungs     0.0115 

Muscles     Traces. 

The  second  indication  is  to  lessen  the  absorption  of  oxalic  acid 
from  the  alimentary  tract  by  lowering  the  acidity.  This  should  not 
be  carried  to  the  point  of  affecting  the  urine,  and  is  usually  accom- 
plished by  small  amounts  of  Vichy  or  similar  mineral  waters.  This 
second  indication  is  of  minor  importance. 

The  third  indication  is  to  increase  the  solvent  power  of  the  urine 


Comparison  of  Magnesium  and  Calcium  Content  of  Various  Vegetable  Foods 
{Elemperer  after  von  Liebig) . 

Ash  Magnesium  Calcium 

Food.                                                                              in  per  cent.  in  per  cent.  in  per  cent. 

of  Substances.  of  the  Ash.  of  the  Ash. 

Millet      5.1  25.8 

Cocoa    4.9  15.9  2.8 

Cornmeal      14.9  6.3 

Rice     0.67  13.4  0.8 

Nut   kernels    13.0  8.6 

Wheat   flour    2.3  10.9  2.2 

Buckwheat     10.3  6.6 

Barley    2.5  9.6  3.5 


528 


DIET  IX  DISEASE 


Ash  Magnesium  Calcium 

Pood.                                                                              in  per  cent.  in  per  cent.  in  per  cent. 

of  Substances.  of  the  Ash.  of  the  Ash. 

Apples     0.27  8.7  4.0 

Coffee  extract    3.4  8.6  3.6 

Peas    2.6  8.1  5.1 

Rve    flour     1.97  7.9  1.02 

Oatmeal      2.3  7.0  3.0 

Tea  extract    3.1  6.8  1.2 

Potatoes     5.0  2.5  0.8 

Grapes    2.25  8.8  36.9 

Cherries      0.4  5.5  7.5 

Plums      0.31  4.7  4.9 

Asparagus      6.4  6.3  15.9 

Lemon  juice    0.2  3.3  7.9 

Bananas      8.8  12.5 

Spinach    2.03  5.3  13.1 

Savoy      2.9  27.9 

Cauliflower     8.8  Trace  21.7 

White  cabbage    11.6  3.7  12.6 

Kohlrabi      8.9  2.3  10.2 

Radish    6.4  3.5  8.8 

Cucumbers     4.8  3.0  6.9 

Gooseberries     0.4  5.8  12.2 

Lentils    2.1  1.9  5.1 

Beans    3.1  6.5  8.6 

Schoten     0.7  6.3  7.8 

Clover      4.8  36.1 

Poppv   seeds    9.5  35.1 

Sorrel      8.3  31.6 

Pears     0.4  5.2  7.9 

Strawberries    Trace  14.2 

Carrots     5.4  2.3  5.6 

Amounts  of  Magnesium  and  Calcium  Contained  in  a  Centigram  of  Dried  Sub- 
stance {Klem,perer  after  Biinge) . 

Magnesium.  Calcium. 

Beef    15.2  2.9 

Albtimin  of  hens'  eggs   13.0  13.0 

Woman's    milk    5.0  24.3 

Yolk  of  egg   6.0  38.0 

Cows'  milk   20.0  151.0 

Fresh  cows'  milk  contains  0.177  per  cent,  of  calcium  oxid  and  0.02  grams  of 
majjnesium  oxid  in  100  ccm. 


for  calcium  oxalate  and  so  prevent  its  deposition.  This  is  accom- 
plished by  increasing  the  fluid  and  so  increasing  the  amount  of  urine 
excreted,  and  by  increasing  the  acid  phosphates,  especially  the  mag- 
nesium salts,  in  the  urine  and  diminishing  the  amount  of  lime  salts. 
In  the  table  the  magnesium  and  calcium  worth  of  various  foods 
is  given,  and  this  table  will  be  found  of  great  practical  value  in 
arranging  diet-lists.  The  foods  containing  more  lime  than  mag- 
nesium are  to  be  avoided,  whilst  the  foods  containing  an  excess  of 
magnesium  are  to  be  chosen.  This  may  also  be  aided  by  the  ad- 
ministration of  small  doses  of  magnesium  sulphate.  Klemperer 
recommends  about  2  grams  (30  grains)  a  day,  to  be  given  over  a  long 
period  of  time.  The  acidity  of  the  urine  is  also  increased  by  the  meat 
diet  usually  given  in  oxaluria. 


DIET  IS  DltiEASES  OF  THE  GENITOURINARY  SYSTEM  529 

The  following  diet-list  will  be  found  of  service : 

AUowahle. — Meat  or  fish  of  any  kind  except  glands. 

Milk  and  eggs  are  excluded  by  Klemperer  on  account  of  their  lime 
content,  but  Minkowski  is  of  the  opinion  that  small  quantities  are 
allowable.  If  the  symptoms  are  pronounced  they  should  be  forbidden, 
and  in  any  case  used  sparingly  if  at  all. 

Fat  of  any  kind  may  be  given  except  the  yolk  of  an  egg. 

Stale  bread  and  zwieback  are  the  best  carbohydrates,  but  rice, 
barley,  and  hominy  may  be  given  and  all  the  legumes.  Potatoes  may 
be  allowed.     Apples  are  the  best  fruit. 

Beverages. — Water,  beer,  and  weak  coffee  may  be  given.  Alcohol 
may  or  may  not  be  given,  according  to  the  individual  and  circum- 
stances. It  neither  increases  nor  diminishes  the  excretion  of  oxalic 
acid. 

Avoid. — All  glands,  such  as  thymus,  pancreas,  liver,  and  the  like. 
Gelatin,  calves '-foot  .jelly,  and  similar  dishes. 

All  fruits  and  vegetables  containing  much  oxalic  acid — as  spinach, 
sorrel,  rhubarb,  cabbage,  turnips,  in  a  word  all  vegetables  except  the 
legumes. 

Tea,  chocolate,  and  cocoa. 

All  rich  and  indigestible  pastries  and  cakes. 

Indicanuria. — Underbill  found  that  when  gelatin  was  fed  to  a  dog 
as  the  chief  nitrogenous  constituent  of  the  diet,  the  urinary  indican 
was  greatly  decreased,  or  if  the  indican  was  decreased  by  feeding  the 
animal  a  diet  poor  in  nitrogen,  the  subsequent  administration  of 
gelatin  does  not  materially  increase  the  output  of  indican.  This 
might  be  used  in  the  diet  of  patients  with  indicanuria.  If  otherwise 
permissible  the  nitrogenous  food  might  be  diminished  and  gelatin 
added  to  the  diet  instead.  There  have  been  no  clinical  reports  on 
this  subject. 

Cystinuria. — Patients  with  cystinuria  should  live  upon  carbohy- 
drates, and  fats  with  the  minimum  amount  of  nitrogenous  food.  The 
protein  may  be  reduced  to  50  or  60  drams  a  day  for  an  individual 
weighing  70  kilos. 

Albuminuria  is  not,  as  a  rule,  caused  by  the  ingestion  of  certain 
foods  by  healthy  individuals.  Some  persons,  however,  possess  the 
remarkable  idiosyncrasy  that  egg-albumin,  or  even  cheese  or  other 
articles  of  diet,  may  cause  a  temporary  albuminuria.  These  cases 
are  of  unusual  occurrence.  (The  student  is  referred  to  text-books 
on  clinical  diagnosis  or  internal  medicine  for  information  regarding 
the  many  causes  of  albuminuria.) 

Too  much  stress  is  ordinarily  placed  on  the  presence  of  albumin  in 
the  urine.  As  Emerson  has  shown,  the  percentage  of  albumin  is  the 
best  index  as  to  the  progress  of  a  case  of  alhuminuria.  It  must  be 
borne  in  mind,  however,  that  this  may  or  may  not  be  so  of  a  case  of 
nephritis.  In  acute  nephritis  the  urine  is  a  fairly  accurate  guide, 
34 


530 


DIET  IN  DISEASE 


improvement  in  the  kidney  condition  being  usually  indicated  by  a 
diminution  of  the  albumin  and  of  blood  in  the  urine,  and  by  an 
increase  in  the  amount  of  urine  excreted.  In  subacute  conditions  the 
same  may  hold  true,  whereas  in  chronic  nephritis  the  variations  in 
the  amount  of  albumin  are  most  untrustworthy  guides  as  to  the 
patient's  condition.  A  mere  change  in  the  diet,  whether  from  a  meat 
to  a  milk  diet,  or  any  other  decided  change,  may  be  followed  by  an 
increase  in  the  amount  of  albumin  for  some  days.  There  are  also 
variations  in  the  amount  of  albumin  excreted  that  are  due  to  influ- 
ences not  as  yet  understood. 

Renal  Tests. — There  are  numerous  tests  for  renal  function,  most 
of  Avhich  consider  the  elimination  as  a  whole,  but  as.Mosenthal  and 
Lewis  and  others  have  pointed  out  the  glomerule  and  the  different 
subdivisions  of  the  uriniferous  tubules  react  differently  to  various 
substances  and  to  the  different  extrarenal  factors  as  fever,  cardiac 
failure,  etc.  A  kidney  may  retain  water  or  salt  or  urea  or  phosphates 
or  sulphates  or  any  of  the  urinary  constituents  and  the  remainder 
may  pass  freely. 

The  phenolsulphonephthalein  test  is  most  frequently  employed. 
(For  the  technic  of  these  tests  the  reader  is  referred  to  the  textbook 
on  diagnosis.)  Others  that  are  employed  are  the  estimation  of  the 
nonprotein  nitrogen  of  the  blood,  the  estimation  of  the  urea  of  the 
blood,  Ambard's  coefficient  of  urea  excretion  and  the  test  meal  for 
renal  function.  The  following  tables  of  Mosenthal  and  Lewis  (Jour- 
nal of  the  American  Medical  Sciences,  September  23,  1916,  yol. 
Ixvii,  p.  933)  illustrate  the  findings  in  various  degrees  of  loss  of 
kidney  function.     In  addition  water  and  salt  and  lactose  tests  may 

Scale  of  Degree  of  Impairment  of  Renal  Function  as  Indicated  hy  the  Tests 
Employed.      (Mosenthal  and  Lewis.) 


Nonprotein 

UreaN 

Ambard's 

Phenol- 

Nof 

of 

Coefficient 

Degree  of  Impairment 

sulphone- 

the 

the 

of 

of  Renal  Function. 

phthalein, 

Blood, 

Blood, 

Urea 

per  cent. 

Mg.  per 

Mg.  per 

Excre- 

100 C.c. 

100  C.c. 

tion. 

Normal     <> 

60+ 

30— 

15— 

0.090 — 

Slight     + 

59-40 

31-45 

16-27 

0.091-0.115 

Moderate      H — f- 

39-25 

46-65 

28-44 

0.116-0.220 

Marked    +++ 

24-11 

66-90 

45-64 

0.221-0.350 

Maximal     ++++ 

10-   0 

91  + 

65  + 

0.351  + 

Test   Meal   for   Renal   Function. 


Night 
Urine. 

Variations  in  Sp.  G.  when  the 
Highest  Sp.  G.  is  : 

C.c. 

Sp.  G. 

18 

17-15 

14  and  13 

12  — 

Normal     0 

Slight     + 

Moderate    -] — h 

Marked     +++ 

Maximal     ++++ 

400 — 
401-600 
601  + 

18+ 

16  and  17 

15— 

9+ 
8—5 
4 — 

6+ 

5  and  4 

3 — 

6+ 

4  and  5 

3 — 

6+ 
5— 

be  used.     The  interpretation  of  findings  is  often  difficult  as  there 
may  be  many  extrarenal  factors  to  consider  arid  they  should  always 


t 


DIET  IN  DISEASES  OF  THE  GENITO-VRINARY  SYSTEM  531 

be  taken  into  account  and  the  experienced  clinician  will  watch  his 
patient  closely  and  not  depend  too  much  on  the  results  of  the  various 
tests.  The  kidney,  like  the  other  organs,  is  furnished  with  a  large 
factor  of  safety  so  that  considerable  impairment  may  be  present  before 
these  tests  for  renal  insufficiency  show  up  in  the  urine,  so  that  the 
early  states  will  depend  for  diagnosis  and  treatment  on  the  older 
methods  of  blood  pressure,  ordinary  urinary  findings,  clinical  history 
and  the  like. 

The  earlier  clinical  studies  were  made  with  reference  to  the 
anatomic  chariges  in  the  kidney.  At  first  it  was  hoped  that  the  renal 
function  tests  might  correlate  the  anatomic  and  clinical  findings,  but 
this  has  not  been  the  case  and  even  the  most  sanguine  students  do  not 
hope  to  be  able  to  determine  the  anatomical  changes.  The  kidney 
may  be  but  little  changed  anatomically  and  yet  show  marked  func- 
tional disturbance  and  conversely.  The  chief  value  of  the  tests  is  in 
prognosis,  but  even  then  they  have  not  been  used  sufficiently  long  to 
enable  one  to  make  any  very  dogmatic  statements.  In  this  regard  the 
tests  are  of  most  importance  in  the  chronic  interstitial  nephritis  cases 
with  marked  vessel  changes.  Even  in  these  cases  there  are  many 
atypical  findings. 

The  phenolsulphonephthalein  test  of  Rowntree  and  Geraghty  con- 
sists of  the  injection  of  1.0  c.c.  of  a  solution  of  the  dye  intramuscularly 
and  the  determination  by  simple  methods  of  the  amount  excreted  in 
the  first  two  hours.  Normally  this  should  be  60  per  cent,  or  over  and 
if  it  falls  below  this  the  renal  function  is  impaired.  (See  Mosenthal 
and  Lewis'  table.)  McLean  has  shown  that  the  output  practically 
parallels  the  urea  index  except  where  the  patients  have  cardiac  insuf- 
ficiency and  are  not  excreting  sufficient  water. 

Another  type  of  test  consists  in  examining  the  blood,  usually  for  the 
nonprotein  nitrogen  and  the  urea  nitrogen,  sometimes  for  uric  acid 
and  creatinin.  The  normal  products  of  metabolism  circulate  in  the 
blood  and  are  excreted  by  the  kidney  so  that  more  or  less  definite  per- 
centages are  in  the  blood.  If  the  kidney  is  impaired  they  may 
accumulate  in  the  blood,  but  they  may  also  accumulate  owing  to  dis- 
turbances of  metabolism  in  which  the  waste  is  abnormally  high  or 
normally  when  the  individual  is  taking  a  diet  rich  in  nitrogen.  The 
normal  limits  are  still  a  question  of  investigation.  The  upper  normal 
limit  is  usually  placed  at  30  mg.  of  nonprotein  nitrogen  in  100  c.c.  of 
blood.  As  high  as  44  mg.  have  been  found  in  supposedly  normal 
individuals. 

The  urea  nitrogen  limit  seems  to  be  about  15  mg.  per  100  c.c.  of 
blood,  with  some  variations. 

Both  of  the  above  are  subject  to  variations  according  to  the  diet  of 
the  patient,  so  that  a  standardized  diet  is  best  used.  In  order  to  get 
more    accurate    information    Ambard    suggested    the    study    of    the 


532  DIET  IN  DISEASE 

amount  of  urea  in  the  blood  and  the  amount  excreted  in  the  urine  in 
a  given  space  of  time.  This  relation  is  usually  spoken  of  as  the 
Ambard  coefficient  and  the  formula  is  as  follows : 


K  = 


In  which    K  ^  The  coefficient  of  urea  excretion. 
Ur  =  Urea  grams  per  liter  of  blood. 

D  =  Urea  grams  excreted  in  urine  in  twenty-four  hours. 

C  =  Urea  grams  per  liter  of  urine. 

P  =  Body  weight  in  kilograms. 
70  =  Standard  body  weight  in  kilograms. 
2.5  =  Standard  concentration  of  urea  grams  per  liter  of  urine. 

The  normal  coefficient  ranges  from  0.06  to  0.09.  The  significance  of 
the  changes  is  shown  in  the  table,  McLean  suggests  using  what  he 
calls  the  urea  index.  With  the  normal  relation  expressed  as  100,  the 
figures  are  more  easily  remembered,  but  it  complicates  the  literature. 
As  we  have  seen  the  Ambard  coefficient  and  the  phenolsulphoneph- 
thalein  tests  run  sufficiently  close  for  practical  purposes.  The  other 
tests  can  only  be  carried  out  in  a  hospital  with  good  laboratory  facil- 
ities. For  the  present  they  will  be  confined  to  hospital  and  research 
work.  These  tests  all  need  much  further  investigation,  but  show  the 
trend  of  modern  thought  in  regard  to  the  problem  of  nephritis. 

Another  test  of  greater  practical  significance  has  been  put  into 
practice  by  Hedinger  and  Schlayer  and  in  this  country  by  various 
workers  among  whom  may  be  mentioned  Mosenthal  and  Christian. 
This  test  consists  of  putting  the  patient  on  a  standardized  fluid  intake 
and  on  a  standard  diet.  No  food  or  fluid  is  taken  except  as  indicated 
in  the  diet  lists  for  testing  renal  function  given  below.  The  urine  is 
collected  every  two  hours  during  the  day  and  a  night  specimen  of 
some  10  to  12  hours.  In  normal  persons  the  quantity  of  night  urine 
is  small,  400  c.c.  or  less,  and  of  a  specific  gravity  of  from  1.018  or  over. 
The  day  urine  is  1.018  or  over  and  varies  nine  points  or  more  from  the 
highest  to  the  lowest.  (See  table.)  When  the  renal  function  is 
impaired  the  maximal  specific  gravity  is  lowered,  the -specific  gravity 
may  be  fixed  and  there  is  an  increase  in  the  amount  of  night  urine. 
This  test  is  more  liable  to  show  low  grades  of  impairment  than  the 
others. 

The  sodium  chloride  and  nitrogen  excretion  may  be  studied  at  the 
same  time  and  the  management  of  the  diet  directed  according  to  the 
findings.  If  sodium  chloride  is  not  excreted  well  it  should  be  dimin- 
ished. The  nitrogen  intake  should  be  kept  within  the  limits  of  the 
patient's  ability  to  utilize  it  and  excrete  the  end  products.  Event- 
ually the  point  may  be  reached  where  simple  methods  will  indicate  the 
amounts  of  phosphates,  sulphates,  etc.,  that  the  patient  can  use  to  the 


DIET  ly  DISEASES  OF  THE  GEMTO-TliiyARY  SYSTEM  533 

best  advantage,  and  diets  arranged  accordingly.  This  time,  as  far  as 
the  general  practitioner  is  concerned,  is  far  off  and  for  the  present 
the  greater  part  of  the  patients  of  nephritis  must  needs  depend  on  the 
skill  of  the  clinician  for  the  regulation  of  their  diet  rather  than  the 
laboratory  lists. 

Salt  Test. — The  average  diet  contains  about  10  to  12  grams  sodium 
chlorid  and  an  equal  amount  may  be  ingested  and  be  excreted  in 
twenty-four  hours.  The  ability  of  the  kidney  to  concentrate  the  salt 
in  solutions  may  be  affected  in  some  kidney  diseases  and  if  much  salt 
is  given  it  is  retained  in  the  body.  The  salt  test  should  be  used  with 
great  caution  in  nephritis,  particularly  the  acute  cases.  The  patient 
is  put  on  a  constant  diet  with  a  constant  water  intake.  From  5  to  10 
grams  of  sodium  chlorid  are  given,  usually  in  the  morning.  The 
amount  excreted  is  determined,  the  concentration  estimated  and  the 
total  amount  of  urine  measured. 

Water  Intake  and  Test. — In  health  about  two-thirds  of  the  daily 
intake  of  water  is  excreted  through  the  kidneys,  the  remainder  being 
excreted  through  the  lungs,  bowels,  or  skin.  The  water  passes 
through  the  glomeruli.  Normally  the  excretion  follows  the  fluid 
intake,  but  in  disease  there  may  be  either  polyuria  or  oliguria 
or  even  anuria.  Oliguria  presupposes  a  more  marked  glomerural 
change  than  polyuria.  There  are  many  factors  outside  the  kidney 
which  influence  water  excretion,  but  the  kidney  is  the  regulating 
organ.  The  specific  gravity  fluctuates,  but  the  fluctuations  are  less  in 
diseased  conditions.  The  kidney  also  possesses  the  power  to  concen- 
trate the  urine  so  that  even  if  the  water  intake  is  small  the  solids 
excreted  in  the  urine  are  sufficient  to  keep  the  body  free  from  waste 
products.  In  some  diseased  conditions  the  kidney  loses  this  function 
and  the  specific  gravity  may  not  exceed  1.012.  The  excretion  of  solids 
may  not  always  be  sufficient  to  keep  the  body  free  from  the  waste 
products  unless  the  amount  of  water  ingested  is  increased.  Various 
tests  have  been  suggested,  all  of  which  should  be  judged  with  a 
knowledge  of  the  salt  intake,  the  amount  of  sweating,  the  occurrence 
of  diarrhea,  and  the  amount  of  moisture  in  the  air.  Volhard  and 
Fahr  give  1500  to  2000  c.c.  water  in  one  hour.  Normally  this  is  all 
excreted  in  the  next  tw^enty-four  hours,  together  with  the  usual 
amount  and  in  the  first  half  hour  succeeding  the  ingestion  500  c.c. 
are  excreted. 

Cottet  gives  the  following  test : 

6.30  to  7.00  A.  M.— 600-800  c.c.  water. 
9.00  A.  M. — a  light  breakfast  and  250  c.c  milk. 
Noon — a  liglit  meal  and  400  c.c.  liqnid. 
7.00  P.  M. — a  light  meal  and  400  c.c.  water. 
Collect  urine  7  a.  m.  to  9  p.  m.  and  from  9  P.  M.  to  7  A.  m. 

In  normal  conditions  three  times  as  much  urine  is  passed   in  the  day  as  at 
night.     In  disease  the  night  and  day  excretion  may  be  equal  or  nearly  so. 

Various  test  diets  have  been  devised  for  testing  the  renal  function 


534  DIET  IN  DISEASE 

and  we  reproduce  below  one  constructed  by  Mosenthal  and  used  in 
his  clinic  in  the  Johns  Hopkins  Hospital.  We  have  also  given  a  low 
protein  test  diet  and  a  couple  simple  low  protein  dietaries  for  ordinary- 
use. 

Renal  Function  Test  Diet — Mosenthal. 

For    Date    

All  food  must  be  salt  free  food  from  the  diet  kitchen. 

Salt  for  each  meal  will  be  furnished  in  weighed  amounts. 

All  food  or  fluid  not  taken  must  be  weighed  or  measwed  after  meals  and 
charted  in  the  spaces   belou\ 

Allow  no  food  or  fluid  of  any  kind  except  at  meal  times. 

Note  any  mishaps  or  irregularities  that  occur  in  giving  the  diet  or  collecting 
the  specimens. 

Breakfast,  8  A.  M. 

Boiled  oatmeal — 100  gms. 

Sugar — i  teaspoonful.  ' 

Milk — 30  c.cm.  '.....................................' 

2  slices  bread   (30  gms.  each) . 

Butter — 20  gms. 


CoflFee— 160   c.cm.         \       „^^ 
Sugar— 1   teaspoonful/    "^^^   ^^^^■ 


Milk— 200  c.cm. 

Water — 200  c.cm.  

Dinner.  12  Noon. 

Meat  soup — 180  c.cm.  

Beefsteak — 100  gms.  ■ 

Potato     (baked,    mashed    or    boiled) 

—130  gms.  

Green  vegetables,  as  desired  

2  slices  bread  (30  gms.  each) 

Butter — 20  gms.  

Tea— 180  com.  ]  .' 

Sugar — 1   teaspoonful  >  — 200   c.cm 

Milk— 20  c.cm.  J  

Water — 250  c.cm.  

Pudding  (tapioca  or  rice) — 110  gms 

Supper,  5  p.  M. 

2  eggs,  cooked  in  any  style  

2  slices  bread   (  30  gms.  each )  

Butter — 20  gms.  

Tea — 180  c.cm.  |  

Sugar — 1   teaspoonful  >  — 200   c.cm 

Milk- 20  c.cm.  J  

Fruit    ( stewed  or  fresh )  — 1  portion     

Water — 300  c.cm.  

8  A.  M. 

Xo  food  or  fluid  is  to  be  given  during  the  night  or  until  8  o'clock  the  next 
morning  (after  voiding),  when  the  regular  diet  is  resumed. 

Patient  is  to  emptj-  bladder  at  8  a.  m.  and  at  the  end  of  each  period  as  indi- 
cated below.  The  specimens  are  to  be  collected  for  the  following  periods  in 
properly  labeled  bottles,  to  be  furnished: 

8  A.  M.-IO  a.m.;  10  a.  M.-12  X.;  12  N.-2  P.M.;  2  P.  M.-4  P.M.;  4  P.  M.-6  P.M.; 
6  P.  M.-8   P.  M. ;    8  p.  M.-8   A.  M. 

Specimens  are  to  be  left  in  ward  until  called  for  at  8.30  A.  m.  by  attendant 
from  the  Chemical  Laboratory. 


DIET  IN  DISEASES  OF  THE  GENITO-URINARY  SYSTEM         535 

Loio  Protein  Test  Diet  for  Renal  Function. 

jTor    Date    

All  food  is  to  be  "Low  Protein"  food  from  the  diet  kitchen. 

Salt  for  each  meal  will  be  furnished  in  weighed  amounts. 

Allow  no  -food  or  fluid  of  any  kind  except  at  meal  times. 

Note  any  mishaps  or  irregularities  that  occur  in  giving  the  diet  or  collecting 
the  specimens. 

All  food  or  paid  may  be  taken  in  any  quantity  desired  but  must  be  weighed 
or  measured  and  charted  in  the  spaces  below: 

Breakfast,  S  a.  ir. 

Hominy  cornstarch  

Cream  

Sugar  

Fruit   ( state  kind)  

Butter  •  •  •    

Water  ■  •  •  • 

Dinner,  12  Noon. 
Potato   (state  whether  baked,  mashed 

or  boiled )  

Vegetable   ( state  kind )  

Vegetable   ( state  kind )  

Vegetable   ( state  kind)  

Olive  Oil  

Vinegar  

Butter  

Pudding    (state    whether    cornstarch 

or  tapioca )  

Sugar 

Fruit   ( state  kind ) 

Water  

Supper,  5  P.M. 

Potato   (state  whether  baked,  mashed 

or  boiled )  

Vegetable   ( state  kind ) 

Vegetable   (state  kind) 

Vegetable    ( state  kind)  

Olive  Oil  

Vinegar 

Butter .  - 

Pudding    (state    whether    cornstarch. 

or  tapioca)  •  •  •  • 

Sugar 

Fruit   ( state  kind)  

Water  

8  A.  M. 

No  food  or  fluid  is  to  be  given  during  the  night  or  until  8  o'clock  the  next 
morning   (after  voiding),  when  the  regular  diet  is  resumed. 

Patient  is  to  empty  bladder  at  8  a.  m.  and  at  the  end  of  each  period,  as  indi- 
cated below.  The  specimens  are  to  be  collected  for  the  following  periods,  in 
properly  labeled  bottles,  to  be  furnished  by  the  Chemical  Division  of  the  Medical 
Clinic: 

8  A.  M.-IO  A.M.;  10  A.  M.-12  N. ;  12  N.-2  P.M.;  2  P.  M.-4  P.M.;  4  P.  M.-6  P.M.; 
6  P.  M.-8   p.  M. ;    8  p.  M.-8    A.  M. 

Specimens  are  to  be  left  in  ward  until  called  for  at  8.30  a.  m.  by  attendant 
from  the  Chemical  Laboratory. 

The  following  are  actual  tests  of  renal  function  made  by  Mosen- 
thal : 


536 


DIET  IN  DISEASE 


Test  of  Renal  Function  (Mosenthal) . 

NaCl.  N. 

Time  of  Day.  C.c.  Sp.  Gr.         Per  cent.  Gm.  Per  cent.  Gm. 

8-10      •130  1007  0.32  1.38  0.26  1.12 

10-12      320  1008  0.52  1.66  '        0.34  1.09 

12-2      285  1009  0.42  1.20  0.37  1.05 

2-4      250  1010  0.48  1.20  0.49  1.23 

4-6            156  1013  0.52  0.86  0.61  0.95 

6-8      365  1005  0.20  0.73  0.33  1.20 

Total  dav   1806  ....  7.03  6.64 

Night,  8-8    295  1021  1.06  3.13  1.11  3.27 

Total,  24  hours   2701  10.16  ....  9.91 

Intake    1760  ....  8..50  ....  13.40 

Balance    —  341  ....  —1.66  ....         +3.49 

Impression:  Normal  result.  Note  the  increased  specific  gravity  and  high 
concentration  of  salt  and  nitrogen  in  the  night  specimen.  The  polyuria  and 
low  concentration  of  the  day  specimens  may  be  due  to  the  excess  of  candy  which 
the  patient  is  in  the  habit  of  taking. 

Test  of  Renal  Function  {Mosenthal). 

NaCl.  N. 

Time  of  Day.  C.c.  Sp.  Gr.         Per  cent.  Gm.  Per  cent.  Gm. 

8-10   385  1007 

10-12   112  1014 

12-2   178  1013 

2-4  136  1015 

4-6  176  1015 

6-8  226  1009 

Total  dav   1213  0.34  4.12  0.55  6.67 

Night,   8-8    622  1013  0.58  3.61  0.58  ;^.61 

Total,  24  hours   1835  7.73  10.28 

Intake    1760  8.,50  13.40 

Balance    —  75  +  0.77  +  3.12 

Impression:  Low  specific  gravity  (maximum  1015  instead  of  a  normal  of 
1018).  Variation  of  specific  gravity  is  8  degrees  (normal  9  degrees).  A  slight 
but  distinct  nocturnal  polyuria.     A  moderate  impairment  of  renal  function. 


Test  of  Renal  Function  (Mosenthal) . 

NaCl.  N. 

Time  of  Day.  C.c.  Sp.  Gr.         Per  cent.  Gm.  Per  cent.  Gm. 

8-10     77  1012 

10-12      85  iOll 

12-2      69  1013 

2-4     71  1012 

4-6     61  1011 

6-8      80  1011 

Total  day   443  0.24  1.06  0.50  2.22 

Night,   8-8    595  1010  0.25  1.48  0.42  2.49 

Total  24  hours    1038  2.54  4.71 

Intake    1610  6.50  12.00 

Balance     -|-  572  -f  3.96  -|-  7.29 

Impression:     Marked  fixation  of  the  specific  gravity  at  a  lo     level.     A  maxi- 
mal impairment  of  renal  function. 


DIET  1\  DISEASES  OF  THE  GENlTO-VRI^iARY  SYSTEM 


537 


THE  JOHNS  HOPKINS  HOSPITAL. 

Low  Protein  Diet. 

Breakfast:       Sherry,  oU  c.em. 

Baked  apple,  stewed  prunes,  orange. 
"Hominy  Cornstarch  Cereal."  i 
Cream,  15  c.cm. 
Dinner:  Sherry,  30  c.cm. 

Potato,  baked  or  raasjied. 

String  beans,  cabbage,  carrots,  lettuce,  onions,  tomatoes,  cucumber 

pickles. 
Fruit  cornstarch  pudding,  fruit  tapioca  pudding. 
Supper:  Same  as  dinner. 

Weigh  or  measure  all  foods  eaten   except  salt,   sugar  and  butter, 
which  may  be  used  as  desired,  and  need  not  be  weighed. 
Special  Diet  for  Nephritis.      (Mosenthal.) 

Nitrogen  Content  of  Foods  used  in  Low  Protein  Diet. 
Article  of  Food.  Percentage  of  Nitrogen. 

Cream      .41 

Cereal:  i  "Hominy  Cornstarch"     .13 

Fruit :  Baked   apple    .04 

Orange    .16 

Stewed   prunes    .14 

Vegetables :     Cabbage    .16 

Carrots    .10 

Lettuce    .24 

Onions     .17 

Cucumber  pickle   .10 

Baked  potato   .48 

Mashed  potato    .40 

String  beans    .23 

Tomatoes     .23 

Desserts:  Blackberry  cornstarch  pudding .05 

Prune  cornstarch  pudding   .07 

Apple  tapioca  pudding   .02 

Peach  tapioca  pudding   .06 

1  3  hominy,  J  cornstarch. 


Breakfast — 6  a.  ii. 

Coffee  or  cocoa — 4  oz.  witli  milk  or  sugar. 

Orange — 1. 

Rice  or  oatmeal  cooked  without  salt. 
10   A.  M. 

Milk — 4  oz.,  or  cocoa — 6  oz. 

Salt  free  toast. 

Orange — 1, — if  desired. 
Dinner. 

Small  amount  of  anj'  green  vegetable  or  tomato  cooked  without  salt. 

Egg — 1, — as  de-sired,  without  salt. 

Salt  free  toast — 2  slices. 

Custard — rice  or  sago. 

Pudding. 
4  P.  M. 

Milk — 6  oz. 

Orange — 1, — if  desired. 
Supper. 

Salt  free  toast — 2  slices. 

Egg — 1,  as  desired,  without  salt. 

Tea — 6  oz.,  with  milk  or  sugar,  if  desired. 

Baked  apple  or  stewed  fruit. 


538  DIET  IN  DISEASE 

The  Fluid  Intake. — This  is  always  a  vexing  problem  and  every 
case  must  be  individualized.  As  long  as  the  water  is  not  being  ex- 
creted the  amount  should  be  kept  down.  From  one  to  one  and  a  half 
liters  a  day  being  the  amounts  usually  given  to  relieve  the  intense 
thirst.  As  the  patient  improves  the  excretion  becomes  more  free  and 
the  edema  may  disappear  entirely  or  almost  so.  In  these  cases,  as 
well  as  in  those  in  which  the  excretion  of  water  is  not  particularly 
reduced,  more  fluid  may  be  allowed.  Alkaline  mineral  waters,  such 
as  Celestins  vichj^  may  be  used,  particularly  if  there  is  anj^  acidosis. 

In  addition  to  the  question  of  protecting  the  kidney  by  avoiding 
irritating  foods,  one  should  limit  the  work  of  the  kidney  by  seeing 
that  the  elimination  by  way  of  the  skin  is  free,  and  by  purging  and 
so  making  use  of  the  eliminating  faculties  of  the  bowel.  The  avoid- 
ance of  physical  and  mental  strain  should  also  not  be  forgotten.  The 
times  of  taking  food  should  be  carefully  regulated  and  also  the 
amounts,  the  quantity  taken  at  any  one  feeding  being  limited.  Great 
care  should  be  taken  not  to  over-feed,  the  patient.  On  the  other  hand, 
care  should  be  taken  not  to  have  him  on  an  insufficient  diet.  The  diet 
should  be  arranged  with  reference  to  the  weight  of  the  patient,  care 
being  taken  to  see  that  sufficient  calories  are  given  to  cover  the  theo- 
retic needs.  These  will  be  found  under  the  heading  the  "Total  Food 
Requirements."  Having  determined  the  number  of  calories  the 
amount  to  be  given  in  protein  food  should  be  estimated.  Chittenden 
has  shown,  as  noted  elsewhere,  that  perfect  health  may  be  maintained 
and  a  nitrogen  balance  established  on  a  minimum  requirement  as 
low  as  60  or  70  grams  of  protein  daily  for  a  patient  weighing  70  kilos. 
This  amount  or  whatever  the  patient  is  able  to  manage  as  shown  by 
tests,  should  be  chosen,  first  avoiding  all  the  proteins  that  contain 
much  purin  nitrogen.  The  remainder  of  the  diet  can  be  then  made 
up  from  carbohydrates  and  fats,  taking  great  care  to  scrutinize  the 
articles  of  food  with  reference  to  not  only  their  nitrogen  content,  but 
the  amount  of  sodium  chlorid  which  they  contain.  Under  the  head- 
ing of  the  "Salt  Free  Diet"  a  very  extensive  list  will  be  found  show- 
ing the  percentage  of  sodium  chlorid  and  nitrogen  in  the  various  foods 
in  ordinary  use. 

Acidosis. — This  is  best  combated  in  acute  nephritis  by  the  ad- 
ministration of  alkalies,  either  by  mouth  or  by  the  ^lurphy  drip,  and 
sodium  bicarbonate  is  as  satisfactory  as  anything.  Sometimes  in  very- 
severe  cases  the  alkalies  are  administered  intravenously  and  Fischer 
has  advised  using  14  grams  of  sodium  chlorid  and  10  to  20  grams  of 
sodium  carbonate  (crystalline)  to  a  liter  of  water.  Rowntree  and 
others  have  used  this  fluid,  substituting  sodium  bicarbonate  up  to  4 
per  cent.  This  is  sterilized  in  tightly  stoppered  bottles  in  an  auto- 
clave for  twenty  minutes  and  a  little  free  bicarbonate  is  scattered  in 
the  autoclave.  In  sterilizing  the  bicarbonate  is  changed  to  the  car- 
bonate and  this  may  be  transformed  by  passing  carbon  dioxid  through 


THE  DIET  IN  NEPHRITIS  539 

the  fluid  under  aseptic  precautions,  a  few  drops  of  phenolphthalein 
being  added  as  an  indicator. 

THE  DIET  IN  NEPHRITIS 

Of  g-r'eat  value  in  general  practice  is  the  study  of  the  patient's 
general  condition,  the  blood-pressure  and  the  simple  tests  of  the 
urine.  The  points  of  particular  interest  as  regards  the  diet  are 
the  presence  or  absence  of  albumin  and  casts,  increase  or  decrease  in 
the  amount  in  twenty-four  hours,  the  presence  of  nycturia,  arising  at 
night  to  pass  the  urine,  hyposthenuria,  a  condition  where  the  kidney 
can  no  longer  concentrate  the  urine,  the  twenty-four  hour  specimen 
being  of  the  least  specific  gravity,  usually  not  over  1.012,  and  lastly 
the  presence  or  absence  of  hematuria. 

From  the  standpoint  of  practical  diet  nephritis  may  be  divided 
into  three  groups:  the  acute  cases,  chronic  parenchymatous  nephritis, 
and  chronic  interstitial  nephritis.  The  old  dictum  of  Traube:  "pro- 
tect the  kidneys  and  control  the  heart,"  sums  up  the  subject  very 
well.  One  of  the  first  principles  in  the  dieting  of  patients  with  any 
disease  of  the  kidney  is  to  avoid  giving  substances  that  are  injurious 
to  the  renal  epithelium.  Many  injurious  articles  of  diet  are  known 
by  the  fact  that  they  uniformly  produce  bad  effects.  A  second  group 
founded  on  studies  of  metabolism  has  been  added  by  von  Noorden  and 
others.  He  ascertained  which  end  products  were  easily  excreted 
and  which  with  difficulty  and  advised  the  avoidance  of  broken  up 
end  products  that  are  difficult  of  excretion.  The  patient  should  be 
carefully  protected  from  lead  and  other  poisons  and  all  the  sub- 
stances forbidden  in  gout  are  forbidden  in  nephritis.  In  the  first 
group  are  included  grills  and  roasts,  especially  the  brown  outer  sur- 
face of  these,  strong  sauces,  pastry,  spices  and  condiments  of  all 
kinds,  very  acid  foods,  and  strong  alcoholic  drinks.  The  use  of  tea 
and  coffee  should  be  scrutinized  with  the  greatest  care  and  many  cases 
do  better  without  either.  The  following  list  shows  the  substances 
that  are  excreted  with  ease  or  with  difficulty  in  acute,  subacute  and 
in  the  exacerbations  in  chronic  nephritis: 

Excreted  with  Difficulty.  Easily  Excreted. 

Urea.  Uric  acid. 

Creatinin.  Xanthin  bases. 

Pigments.  Aromatic  substances. 

Hippuric  acid.  Amido-acids. 

Phosphates.  Carbonates. 

Inorganic   sulphates.  Water   (see  below). 
Potassium  salts. 
Water   ( see  below ) . 

Early  in  the  disease  water  is  excreted  with  great  difficulty — with 
more  difficulty  than  even  urea.  As  soon  as  improvement  sets  in, 
however,  it  is  easily  gotten  rid  of.     The  difficulty  probably  lies  in  the 


540  DIET  m  DISEASE 

mechanical  interference  with  its  excretion,  owing  to  the  great  dis- 
tention of  the  blood-vessels  caused  by  the  severe  congestion. 

It  is  necessary  next  to  notice  briefly  the  articles  of  diet  that  give 
rise  to  the  different  end-products  just  mentioned. 

Creatinin  is  derived  from  creatin,  which  is  present  in  meat-ex- 
tracts and  in  meat  broths.  Traces  are  also  found  in  the  white  and  in 
yolk  of  eggs  and  in  meat.     It  is  not  present  in  vegetables. 

Urinnry  Pigments. — Little  is  known  concerning  these.  They  are 
all  probably  derived  from  hemoglobin,  and  there  is  no  way  of  con- 
trolling hemoglobin  metabolism  by  restricting  the  diet.  Substances 
containing  homoglobin  may,  however,  be  omitted  from  the  diet. 

Phosphoric  Acid. — This  is  present  in  large  quantities  in  meat,  yolk 
of  eggs,  milk,  and  many  vegetables.  Milk  is  the  principal  food  to  be 
considered  here,  as  it  is  used  extensively  and  contains  large  quantities 
of  the  acid.  Von  Noorden  suggests  the  use  of  calcium  carbonate  to 
overcome  this  acidity  in  the  patients  on  a  milk  diet. 

Urea  and  Sulphates. — These  are  both  derived  from  albumin.  The 
important  point  to  remember  is  the  fact  that  the  amount  of  protein 
ingested  maj'  be  reduced  to  a  very  small  quantity  if,  at  the  same 
time,  corresponding  quantities  of  carbohydrates  and  fat  are  adminis- 
tered. Von  Noorden  gives  about  a  liter  and  a  half  of  milk  daily,  and 
usually  adds  a  quarter  of  a  liter  of  cream  to  it.  He  warns  against 
the  excessive  use  of  fat  in  nephritis.  Amylaceous  soups  or  gruels  are 
added  to  the  diet  where  necessary. 

Hippuric  Acid. — This  is  derived  from  compounds  (benzoic  esters) 
that  are  contained  in  green  vegetables,  fruits  with  kernels,  and  cran- 
berries. These  should  be  avoided  in  acute  inflammatory  processes  in 
the  kidneys.  Small  quantities  are,  however,  found  in  such  fruits  as 
pears,  apples,  and  many  berries,  particularly  raspberries,  and  in 
grapes.  These  fruits  and  juices  made  from  them  may  be  given  in 
nephritis. 

Acetic  Acid  and  Citric  Acid. — Von  Noorden^  says:  "There  is  an 
old  popular  prejudice  to  the  effect  that  acetic  acid  should  be  alto- 
gether eliminated  from  the  diet  of  patients  suffering  from  renal  dis- 
ease, from  lithiasis,  and  from  bladder  troubles."  Citric  acid  as 
contained  in  lemon-juice  has  been  recommended  as  a  substitute  for 
acetic  acid.  Von  Noorden  states  that  there  is  no  theoretic  or  prac- 
tical objection  to  the  use  of  vinegar  in  diseases  of  kidney,  bladder,  or 
urethra,  and  that  he  has  never  seen  the  slightest  harm  result  from 
its  use. 

Uric  Acid  and  the  Xanthin  Bases. — These  are  relatively  well  ex- 
creted. They  are,  however,  toxic,  and  under  certain  conditions  their 
elimination  may  be  retarded.  In  all  forms  of  nephritis  it  is,  there- 
fore, advisable  to  withhold  all  such  foods  as  favor  the  formation  of 
alloxuric   bodies.     These   are   all   animal   tissues   rich   in   nuclein. — 

1  Von  Xoorden,  Clinical  Treatises  on  l)he  Pathology  and  Therapy  of  Disorders 
of  Metabolism  and  NutriPion,  Part  II,  Nephritis. 


i 


THE  DIET  r\  \EI'IIRITI8  541 

especially  glands, — such  as  sweetbreads,  liver,  spleen,  kidney,  and 
strong  meat  broths. 

Muscle  meat,  of  course,  contains  some  nuelein,  but  not  sufficient 
to  justify  its  exclusion  from  the  diet  on  these  grounds. 

Yon  Noorden  and  others  have  determined,  as  the  result  of  careful 
experimentation,  that  there  is  no  difference  in  the  light  and  dark 
meats  as  regards  the  effects  of  their  end-products  on  the  kidneys. 
This  is  in  direct  variance  with  the  time-honored  view,  but  it  is  ap- 
parently based  on  uncontrovertible  facts. 

Alcohol. — Little  is  known  in  regard  to  the  excretion  of  alcohol  by 
diseased  kidneys.  Alcohol,  whether  taken  in  the  form  of  the  .strong 
or  of  the  weaker  alcoholic  beverages,  is  known  to  act  as  one  of  the 
worst  of  poisons  to  the  kidneys.  That  it  irritates  the  kidneys  di- 
rectly, there  can  be  no  doubt ;  but  it  is  also  true  that  a  certain  amount 
of  alcohol  will  be  eliminated  by  healthy  kidneys  without  harm  to 
them.  This  amount  probably  varies  with  different  individuals  and 
can  not  be  definitely  fixed.  The  amount  that  will  prove  injurious 
to  diseased  kidneys  is  undoubtedly  smaller  than  for  healthy  kidneys. 
Ordinarily,  alcohol  should  be  strictly  avoided,  but  there  are  cases  in 
which  it  may  be  used  with  great  benefit.  Attacks  of  cardiac  weak- 
ness and  a  small,  thready  pulse  may  be  successfully  combated  by 
small,  repeated  doses.  In  certain  cases  where  there  is  nausea,  food 
may  be  retained  when  small  quantities  of  wine  or  diluted  brandy  or 
whisky  are  given. 

Alcohol  is  contained  in  kefir  and  kumiss,  which  are  used  in  large 
quantities  by  physicians  who  would  not  prescribe  it  in  any  of  the 
stronger  forms. 

Acute  Nephritis. — There  is  still  considerable  difference  of  opinion 
concerning  the  best  diet  for  patients  with  this  disease. 

(a)  In  Severe  Cases  where  Secretion  of  the  Urine  is  Greatly  Re- 
duced. In  these  cases  where  the  edema  is  increasing  and  where 
uremia  threatens,  the  amount  of  food  and  drink  should  be  limited  to 
the  smallest  possible  amount.  If  there  is  vomiting,  all  food  should 
be  withdrawn  until  it  subsides.  If  there  is  an  accompanying  acidosis 
it  will  have  to  be  dealt  with  according  to  the  suggestions  made  under 
that  heading.  If  the  patient  is  not  excreting  all  the  fluid  added  to 
the  body  is  retained  and  increases  the  difficulty.  If  the  thirst  is  in- 
tense, water,  in  tablespoonful  doses,  may  be  given,  or  what  is  usually 
better,  ice  may  be  given  to  quench  the  thirst.  The  surplus  water  in 
the  tissues  may  be  removed  by  sweating  or  purging.  When  the  heart 
is  failing  and  the  pulse  is  small  and  thready,  brandy  or  whisky  may 
be  administered  in  small,  frequent  doses.  If  the  patient  is  not  vomit- 
ing, about  one  pint  of  fluid  food  may  be  administered,  preferably 
in  the  form  of  a  gruel  made  out  of  rice  or  barley  flour  or  corn  or 
wheat  flour  may  be  substituted  or  even  potato  starch.  Small  amounts 
of  fruit  juices  may  be  allowed  with  this. 


542  DIET  IN  DISEASE 

Such  a  diet  cannot  be  maintained  ordinarily  for  more  than  four  or 
five  days  without  seriously  impairing  the  strength,  but  usually  at  the 
end  of  this  time  the  patient  is  either  improved  or  succumbs  to  the 
disease.  It  was  formerly  suggested  to  use  milk  in  similar  quantities. 
This  would  seem  to  entail  rather  more  work  on  the  kidney.  As  the 
patient  improves  and  passes  into  the  second  class: 

(b)  The  Cases  in  which  the  Excretion  of  Water  is  Reduced,  but 
in  which  Anuria  does  not  Threaten  Life.  In  these  cases,  as  the  pa- 
tient improves,  the  diet  can  be  gradually  increased.  For  the  first 
week  or  two  the  protein  may  be  kept  at  a  minimum  by  using  the 
gruels  or  purees  mentioned  above  to  which  may  be  added  fruit,  par- 
ticularly those  that  are  rich  in  sugar,  fruit  juices,  such  as  orange 
juice,  grape  juice  or  other  fruit  syrups;  crackers  or  zwieback  may 
also  be  given  and  washed,  unsalted  butter.  As  soon  as  the  acute 
symptoms  have  passed  milk  and  cream  may  be  added  to  the  diet. 
At  this  time  1500  grams  of  milk,  375  grams  of  cream,  50  grams  of 
rice,  50  grams  of  zwieback.  50  grams  of  butter,  20  grams  of  sugar, 
with  a  total  value  of  2900  calories,  might  be  utilized. 

Some  authorities  suggest  a  strict  milk  diet  but  it  would  seem  a 
more  rational  treatment  to  replace  as  much  of  the  milk  as  possible 
by  the  carbohydrates  and  fats.  As  the  patient  improves  the  diet  may 
be  increased  and  easily  kept  from  becoming  monotonous  by  using 
the  various  cereals,  adding  bread  and  various  dishes,  such  as  are 
made  out  of  arrowroot  or  cornstarch,  which  may  be  flavored  with 
fruit  juices,  orange  juice,  or  lemon  or  grapefruit  juice  to  which 
lactose  has  been  added  and  junkets  and  custards.  If  the  digestion 
is  very  good  the  butter  and  other  fats  may  be  increased  and  later  the 
more  easily  digested  vegetables  may  be  added,  and  as  convalescence 
is  established,  spinach  and  cauliflower  tops  and  peas  and  other  such 
things  may  be  used  to  introduce  variety. 

As  to  beverages,  water,  plain  or  carbonated,  mineral  waters,  fruit- 
juice  and  water  (lemonade,  etc.).  If  the  patient  prefers  milk,  from 
four  to  seven  pints  may  be  given  daily,  diluted  with  a  carbonated 
water.  If  it  causes  diarrhea,  lime-water  should  be  added  to  the  milk, 
or  if  there  is  constipation,  magnesia  solution  or  citrate  of  magnesia 
may  be  given  instead.  If  symptoms  of  indigestion  appear,  the  milk 
may  be  skimmed,  or  buttermilk  substituted.  If  the  stomach  becomes 
disordered,  kumiss  may  be  given  in  place  of  milk,  or  rice,  or  barley, 
or  arrowroot  gruel  may  be  substituted  for  it.  If  vomiting  occurs, 
the  stomach  should  be  given  complete  rest,  after  which  carbonated 
water  may  be  allowed.  A  favorite  drink  under  these  conditions,  or 
in  fact  at  any  time  in  the  course  of  an  acute  nephritis,  is  the  im- 
perial drink,  made  by  dissolving  a  dram  of  cream  of  tartar  in  a  pint 
of  boiling  water  and  adding  the  juice  of  half  a  lemon  and  a  little 
sugar;  this  should  be  given  cold. 

If  the  course  of  the  disease  is  slow  and  the  condition  subacute, 


TEE  DIET  IN  NEPHRITIS  543 

the  diet  must  be  increased  or  the  patient's  strength  will  fail.  In 
these  cases  small  amounts  of  meat  may  be  added  to  the  dietary.  The 
effect  on  the  urine  and  temperature  must  be  carefully  watched.  If 
there  is  marked  disturbance,  the  meat  should  be  discontinued  and 
then  repeated  after  several  days.  The  general  condition  of  the  pa- 
tient is  a  safe  guide,  and  he  must  not  be  allowed  to  starve  to  death 
because  a  small  amount  of  albumin  appears  in  his  urine. 

Chronic  Parenchymatous  Nephritis. — In  this  disease  the  patient's 
mode  of  life  must  be  carefully  regulated.  The  amount  of  exercise 
and  rest  and  the  time  to  take  the  meals  and  the  quantity  require 
particular  attention.  The  general  principles  outlined  above  hold 
good  in  these  cases.  The  first  point  should  be  to  avoid  all  irritating 
articles  of  food,  the  second  to  supply  protein  just  sufficient  to  cover 
the  patient's  needs  and  the  deficiency  in  the  number  of  calories  re- 
quired is  to  be  made  up  by  suitable  carbohydrates  and  fats.  Care 
should  be  taken  in  the  severer  cases  not  to  starve  the  patient.  No 
hard  and  fast  rule  can  be  laid  down  as  to  the  restriction  of  protein, 
but  every  case  should  be  dealt  with  according  to  the  particular  re- 
quirements. Where  the  physician  has  access  to  suitable  laboratory 
facilities,  tests  of  the  renal  function  made  from  time  to  time  show 
whether  the  case  is  progressing  or  getting  worse,  and  the  diet  can  be 
arranged  accordingly. 

The  protein  can  be  kept  at  a  low  amount  for  very  long  periods  of 
time  if  care  is  taken  not  to  try  to  get  the  amount  below  what  is 
actually  required  to  prevent  nitrogen  loss.  A  protein-free  day  every 
now  and  then  is  often  of  value  and  in  the  exacerbations  which  often 
occur,  the  protein  may  be  cut  in  half  until  the  acute  symptoms  sub- 
side. Milk,  buttermilk,  and  the  other  foods  made  from  milk  are  very 
generally  used  to  supply  a  part  of  the  protein,  but  care  should  be 
taken  not  to  insist  on  too  much  milk,  inasmuch  as  sooner  or  later  the 
patient  will  become  extremely  tired  of  it.  If  the  patient  stands  it 
well,  and  they  usually  will,  one-half  of  the  protein  may  be  given  in 
the  form  of  fresh  meat  or  fresh  fish.  Eggs  or  vegetables  may  be  used 
as  a  substitute  for  part  of  this.  By  so  doing  a  palatable  and,  at  the 
same  time,  a  satisfactory  diet  can  be  easily  arranged.  Peas  and  beans 
may  be  used  and  the  carbohydrate  part  of  the  diet  made  up  from 
the  various  cereals  and  fruits  that  have  already  been  suggested. 
Fats  are  best  given  in  the  form  of  cream  or  butter.  Sugar,  fruit 
syrups,  jellies  and  compotes  may  be  given,  using  especially  apples, 
pears,  or  raspberries.  Sago  and  tapioca,  arrowroot  and  cornstarch 
should  not  be  forgotten  as  furnishing  satisfactory  materials  for 
desserts.  The  various  infant's  and  invalid's  foods  may  also  be  used. 
Tea  and  coffee  in  small  amounts  are  generally  allowable;  alcohol  is 
prohibited,  except  as  needed  in  special  cases. 

The  fluid  intake  will  depend  upon  the  individual.  If  there  is 
edema  the  amount  should  be  limited  to  from  one  to  one  and  a  half 


544  DIET  IN  DISEASE 

liters  a  day,  or  if  the  edema  is  marked  smaller  amounts  may  be  used 
until  the  water  excretion  increases. 

The  amount  of  salt  allowed  will  have  to  be  regulated  according 
to  the  patient's  ability  to  excrete  it.  Where  there  is  edema  the 
amount  should  be  cut  down  to  a  minimum,  using  the  foods  from  the 
lists  given  under  the  Salt-free  Diet.  Very  often  salt  is  withheld  un- 
necessarily long  and  the  salt  elimination  may  be  tested  from  time  to 
time  by  adding  small  amounts  to  the  diet  and  noting  changes  that 
take  place  in  the  urine  or  excretion  and  the  thirst  as  to  whether 
edema  is  produced.     (See  also  Salt-free  Diet  and  the  Karell  Diet.) 

Nephrosis. — Chronic  parenchymatous  nephritis  includes  a  number 
of  widely  differing  kidney  lesions  which,  from  the  standpoint  of 
practice  at  present,  there  is  little  need  for  separating.  There  are, 
however,  certain  cases  of  what  has  been  called  nephrosis  and  certain 
cases  of  diffuse  nephritis  occurring  in  relatively  young  women  during 
or  after  pregnancy  and  in  older  diabetics,  which  have  been  studied 
by  Epstein  (American  Journal  of  the  Medical  Sciences,  November, 
1917,  p.  638).  In  these  cases  the  total  blood  protein  is  low  and 
there  is  a  relative  increase  in  the  globulin  content.  Sometimes  it 
makes  up  nearly  all  of  the  nitrogenous  matter  of  the  blood.  There  is 
an  increase  of  the  fats  and  lipoids  in  the  blood.  The  urine  usually 
has  a  high  specific  gravity,  is  deficient  in  chlorides,  and  very  high 
in  albumin.  In  nephrosis  the  formed  blood  elements  are  not  found 
in  the  urine  and  the  blood  pressure  is  not  elevated.  In  the  chronic 
diffuse  nephritis  the  blood  pressure  may  be  very  high.  The  enor- 
mous protein  loss  in  the  urine  is  the  important  thing.  Epstein 
recommends  a  marked  innovation,  that  of  increasing  the  proteins, 
eliminating  the  fats,  and  limiting  the  carbohydrates,  the  last  to 
promote  a  maximum  assimilation  of  the  proteins  and  to  limit  the 
water  retention. 

Diet  employed:  Daily  amount. 

Food  value   1280-2500  calories 

Proteins     120-240  grams 

Fats    ( unavoidable )     20-40  grams 

Carbohydrates    150-300  grams 

Articles  used :  lean  veal,  lean  ham,  whites  of  eggs,  oysters,  gelatin, 
lima  beans,  lentils,  split  peas,  green  peas,  mushrooms,  rice,  oatmeal, 
bananas,  skimmed  milk,  coffee,  tea,  cocoa. 

The  fluid  is  restricted  to  the  amount  needed  to  make  the  patient 
comfortable,  generally  1200  to  1500  c.c.  Salt  is  allowed  sufficient  to 
make  the  food  palatable.  From  a  small  number  treated  Epstein  has 
had  good  results,  if  somewhat  slow  of  accomplishment.  The  blood 
gradually  returns  to  normal,  the  amount  of  urine  excreted  increases 
and  the  edema  gradually  disappears.  The  albuminuria  decreases 
and  the  general  health  improves.     Bleeding  (500  c.c.)  and  replacing 


THE  DIET  IN  NEPHRITIS  545 

by    transfusion    may    be    used    in    connection    with    this    treatment. 

Acute  Nephritis  Due  to  Mercuric  Chlorid. — Lambert  and  Pat- 
terson (Archives  of  Internal  Medicine,  1915,  xvi,  871)  have  out- 
lined the  treatment  of  these  cases  as  follows: 

"1.  The  patient  is  given  every  other  hour  8  ounces  of  the  following 
mixture :  Potassium  bitartrate,  1  dram ;  sugar,  1  dram ;  lactose,  one- 
half  ounce;  lemon  juice,  1  ounce;  boiled  water,  16  ounces.  Eight 
ounces  of  milk  are  administered  every  alternate  hour. 

"2.  The  drop  method  of  rectal  irrigation  with  a  solution  of  potas- 
sium acetate,  a  dram  to  the  pint,  is  given  continuously.  The  amounts 
of  urine  secreted  under  this  treatment  are  verj^  large.  In  one  case, 
269  ounces  were  passed  in  twenty-four  hours  on  the  fourteenth  day 
of  treatment. 

"3.  The  stomach  is  washed  out  twice  daily. 

''4.  The  colon  is  irrigated  twice  daily,  in  order  to  wavsh  out  what- 
ever poison  has  been  eliminated  in  that  way. 

"5.  The  patient  is  given  a  daily  sweat  in  a  hot  pack. 

"It  is  imperative  to  emphasize  the  necessity  of  keeping  up  the 
treatment  with  the  colonic  drip  enteroclysis  day  and  night  without 
interruption.  It  entails  discomfort  for  the  patient,  but  the  victims 
of  accidental  poisoning  are  always  willing  to  do  anything  to  recover 
from  their  plight,  and  the  attempted  suicide  usually  repents  rapidly 
of  his  error,  and  the  hope  of  his  life  being  saved  stimulates  his  patience 
and  desire  to  cooperate. 

"In  cases  in  which  one  single  dose  has  been  taken,  after  two  nega- 
tive examinations  of  the  urine,  on  successive  days,  it  seems  legitimate 
to  stop  the  treatment.  For  the  less  severe  cases,  a  week  may  be  a 
sufficient  time  for  treatment.  When  large  or  successive  doses  have 
been  taken,  or  when  there  is  a  preexisting  kidney  lesion,  or  when 
treatment  begins  several  days  after  the  poison  is  taken,  longer  periods 
of  treatment,  up  to  two  or  three  weeks,  are  necessary. ' ' 

Chronic  Interstitial  Nephritis. — Cases  of  this  disease  require  a 
special  study  and  the  nature  of  the  individual  and  the  stage  of  the 
disease  must  be  taken  into  careful  consideration.  This  is  usually  a 
disease  of  older  life.  Individuals  are  used  to  the  habits  of  a  lifetime 
and  very  often  much  harm  is  done  by  the  unnecessary  arbitrary 
rulings  of  physicians.  The  habits  of  the  individual  should  be  dis- 
turbed as  little,  as  possible  unless  the  physician  is  certain  that  they 
have  a  direct  influence  upon  the  course  of  the  disease.  Great  care 
should  be  taken  to  avoid  acute  exacerbations.  These,  if  they  do  occur, 
are  to  be  managed  like  an  attack  of  acute  nephritis.  The  disease  is  a 
chronic  one  in  which  cure  is  out  of  the  question.  What  can  be  done 
is  to  so  arrange  the  life  of  the  individual  and  the  diet  as  to  permit 
the  greatest  degree  of  comfort  and  the  largest  amount  of  activity 
compatible  wdth  the  stage  of  the  disease.  The  patient  should  be 
given  as  much  encouragement  as  possible  and  in  many  instances  may 
35 


546  DIET  IX  DISEASE 

be  allowed  to  continue  his  ordinary  work,  but  in  some  instances  this 
may  have  to  be  changed  or  lightened.  If  care  is  taken  to  avoid  all 
excesses  of  every  kind  and  to  live  a  life  according  to  the  rules  of 
hygiene  and  follow  the  instructions,  many  of  these  patients  are  able 
to  work  for  many  years.  Vacations  in  warm,  dry  climates  are  very 
helpful,  outdoor  exercises  of  a  very  moderate  kind,  usually  are  an 
advantage,  but  should  be  carefully  regulated.  Where  the  blood  pres- 
sure is  high  hot  baths  or  carbon  dioxid  and  oxygen  baths  or  warm 
baths  may  be  employed  if  the  myocardium  is  in  good  condition. 

The  first  factor  in  arranging  the  diet  is  to'  maintain  the  strength 
and  weight  of  the  individual  and  for  this  purpose  the  protein  is  first 
considered,  the  amount  taken  being  cut  to  as  low  a  level  as  possible. 
At  present  there  is  a  tendency  to  overdo  the  low  protein  diet  and 
if  the  physician  has  sufficient  laboratory  facilities  sometimes  con- 
siderable information  can  be  obtained  in  this  regard  by  a  study  of 
the  blood  non-protein  nitrogen.  In  view  of  Chittenden's  experiments 
on  healthy  individuals  it  would  seem  advisable  to  try  a  diet  of  60 
grams  for  a  patient  weighing  70  kilos.  On  this  amount,  if  the 
maximum  balance  is  established,  the  excretion  of  nitrogen  should 
be  8  or  9  grams  daily.  Von  Noorden,  averaging  a  series  of  cases  of 
interstitial  nephritis  covering  five  years  experience,  before  Chitten- 
den's experiments,  found  that  for  70  kilos  of  body  weight  the  nitrogen 
ingested  in  males  was  13  to  16  grams  and  in  females  from  11  to  14 
grams,  that  is  about  80  to  100  grams  of  protein  for  the  males  and 
65  to  85  for  the  females.  Making  allowance  for  the  amount  lost  in 
the  feces  the  quantity  taken  was  90  to  102  grams  for  males  and  80 
to  100  grams  for  females.  Based  on  these  figures  he  gives  an  average 
diet  of  milk,  750  c.c,  2  eggs,  bread  and  vegetables  and  meat  for  the 
men,  215  to  315  grams  weighed  raw,  and  women,  155  to  255  grams. 
The  amount  of  meat  in  his  diet  can  certainly  be  made  very  much 
less  with  very  great  advantage,  cutting  it  to  100  to  150  grams  a  day 
according  to  the  condition  of  the  patient.  It  is  rather  a  good  plan  to 
mix  the  protein,  getting  part  from  meat,  eggs,  and  milk  and  part 
from  vegetables.  Having  determined  the  all-important  protein  fac- 
tor of  the  diet  the  remainder  of  the  caloric  needs  of  the  patient  are 
to  be  made  up  of  carbohydrates  and  fats.  Cereals  and  breakfast 
foods  with  sugar  and  cream,  ripe  fruits  and  fruit  juices,  well  cooked 
vegetables  and  simple  desserts  of  compotes  or  puddings  or  fruit 
jellies,  together  with  the  necessary  amount  of  bread,  toast  or  the 
various  kinds  of  crackers,  will  make  up  the  carbohydrate  part  of  the 
diet,  while  butter,  cream,  olive  oil,  may  be  used  to  supply  the  fats, 
in  addition  to  the  fats  that  are  taken  with  the  meats.  Gelatin  jellies 
in  small  amounts  and  green  vegetables  used  as  salads  are  desirable, 
taking  care  not  to  use  salad  dressings  with  undesirable  irritating 
substances.     The  lists  of  foods  in  various  parts  of  the  book  will  be 


THE  DIET  I.\   XEPIIRITIS  547 

found  very  helpful  in  arranging  the  diets,  particularly  the  one  show- 
ing the  amount  of  salt  and  protein  in  ordinary  foods. 

Having  decided  upon  the  foods  that  are  needed  for  the  patient,  the 
next  and  very  important  point  is  to  protect  the  kidney  as  much  as 
possible  from  all  irritating  foods  and  drinks.  All  of  the  foods  men- 
tioned as  being  irritating  at  the  beginning  of  this  section  should  be 
strictly  avoided.  This  includes  all  foods  rich  in  purin  nitrogen, 
lists  of  which  will  be  found  elsewhere.  Spices  of  all  kinds,  celery, 
radishes,  green  peppers,  watercress,  mushrooms  and  asparagus,  the 
last  named,  permitted,  perhaps,  very  sparingly  in  season,  tea,  coffee 
and  cocoa  are  ordinarily  forbidden,  but  may  be  allowed  in  small 
quantities  if  they  do  not  exert  an  injurious  effect  upon  the  heart  and 
the  same  is  true  of  tobacco.  Careful  observations  should  be  made  as 
to  the  effect  upon  the  pulse-rate  and  strength,  upon  the  strength  and 
character  of  the  heart  impulse,  and  to  the  subjective  sensations.  Some 
patients  would  seem  to  do  better  with  small  amounts  of  these  beverages 
than  without  and  patients  accustomed  for  a  lifetime  to  the  use  of 
tobacco  are  often  more  comfortable  mentally  if  permitted  the  use  of 
a  small  amount  once  or  twice  daily. 

In  regard  to  the  use  of  alcohol  total  abstinence  is  the  rule  and  the 
patient  should  not  be  allowed  any  form  of  alcoholic  drink  as  a 
beverage  with  the  exception  if  the  individuals  should  have  been 
alcoholics  for  many  years.  In  old  alcoholics  there  may  be  attacks  of 
weak  heart  or  complete  anorexia  if  the  alcohol  is  withdrawn  at  once, 
so  that  under  certain  circumstances  small  amounts  can  be  permitted. 
This  can  be  gradually  reduced  until  none  is  being  used,  unless  it  is 
found  that  the  appetite  and  general  condition  are  very  much  better 
with  than  without  it.  Ordinarily  alcohol  is  looked  on  with  even  more 
disfavor  in  chronic  interstitial  nephritis  than  in  acute  nephritis. 

In  addition  to  the  restrictions  in  the  way  of  foods  and  drinks 
there  is,  of  course,  great  danger  of  irritating  the  kidney  by  using 
irritating  drugs.  In  this  disease  it  is  well  to  be  cautious  in  the  use 
of  all  drugs.  Owing  to  its  chronicity  and  the  frequent  occurrence  of 
intercurrent  infections,  drugs  are  apt  to  be  used  to  greater  extent 
than  in  any  other  disease  and  excreted  more  slowly  than  during 
health.  Among  the  drugs  that  are  injurious  are  cantharadin,  copaiba, 
turpentine,  salicylic  acid  and  its  derivatives,  phenol,  resorcin,  boric 
acid,  lead,  copper,  silver,  and  mercury  and  their  salts,  iodoform  and 
various  tartar  preparations.  This  list  could  be  very  greatly  extended 
and  it  should  be  remembered  that  any  drug  that  is  excreted  by  the 
kidneys  means  extra  work  for  the  kidney  after  given. 

The  amount  of  fluid  to  be  allowed  a  patient  should  be  carefully 
determined.  Ordinarily  they  are  encouraged  to  take  water,  milk  and 
diuretic  drinks,  a  practice  that  is  usually  followed  by  bad  results 
owing  to  extra  work  thrown  upon  the  heart.     A  large  amount  of  the 


548  DIET  IN  DISEASE 

fluid  taken  into  the  bodj'  and  absorbed  by  the  intestinal  tract  is  ex- 
creted through  the  kidneys.  This  means  increased  blood  pressure 
and  increased  work  for  an  already  over-burdened  heart.  Von  Noor- 
den  limits  the  amount  of  fluid  taken  to  one  and  a  quarter  liters. 
This  includes  all  kinds  of  fluids,  but  does  not  take  into  account  the 
water  in  solid  foods  which  usually  amounts  to  500  to  700  c.c.  daily. 
The  amount  of  fluid  the  patient  is  taking  should  be  determined  by 
measuring  everything  that  he  drinks  for  two  or  three  days  and  then 
this  amount  cut  down  from  250  to  300  c.c.  a  day  until  the  patient  is 
taking  the  desired  quantity.  One  day  a  week  a  drink  day  is  allowed 
on  which  all  the  water  desired  may  be  taken  up  to  two  and  a  half 
liters.  If  it  is  found  that  the  excretion  of  the  solid  contents  of  the 
urine  takes  place  as  rapidly  with  this  restricted  amount  of  water  as 
before  and  that  in  case  the  excretion  is  not  quite  so  good  the  one  day 
a  week  flushing  keeps  the  organism  clean.  In  some  exceptional  cases 
for  two  or  three  months  several  drinking  days  may  be  allowed,  one 
after  the  other,  but  if  there  is  failing  compensation  or  any  appreciable 
dilatation  of  the  left  heart  this  flushing  out  should  not  be  resorted  to. 
The  desire  for  water  is  greatly  lessened  by  placing  the  patient  on  a 
salt-free  or  a  comparatively  sodium  chlorid-free  diet,  as  suggested 
for  chronic  parenchymatous  nephritis.  In  many  cases  all  that  is  nec- 
essary is  to  take  away  the  patient 's  salt  cellar.  In  the  more  advanced 
cases  the  salt-free  foods  may  be  chosen.  Care  should  be  taken  not  to 
overdo  the  salt-free  diet. 

Care  should  also  be  taken  not  to  allow  patients  who  have  a  leaning 
toward  obesity  too  much  carbohydrate  material.  This  is  frequently 
done  in  cases  of  contracted  kidney,  usually  with  bad  results.  On  the 
other  hand,  in  thin  patients,  if  there  is  no  attendant  dyspepsia  a 
diet  rich  in  carbohydrates  may  very  greatly  improve  the  patient's 

condition. 

FLOATING  KIDNEY 

In  this  condition  two  things  are  to  be  especiall}^  recommended — 
viz.,  rest  and  food.  The  diet  should  be  one  that  will  cause  the  patient 
to  take  on  as  much  flesh  as  possible.  ]\Iany  eases  of  movable  kidney 
come  on  in  nervous  individuals  who  have  lost  flesh,  and  when  the 
fat  normally  surrounding  the  kidney  is  replaced,  the  organ  no  longer 
floats  about.  The  rest  cure  is  especially  recommended  in  those  cases 
that  occur  in  nervous  people  who  have  lost  flesh  rapidly.  Time  and 
patience  are  required,  and  the  treatment  often  fails  because  it  is  not 
persisted  in  for  a  sufficiently  long  time.  In  cases  of  long  standing  a 
diet  similar  to  that  recommended  in  gastroptosis  and  enteroptosis 
should  be  prescribed. 

AMYLOID  KIDNEY 

This  condition  requires  a  supporting  diet  of  good  food,  and  measures 
directed  toward  removing  the  cause  of  the  amyloid  disease. 


THE  DIET  IX  XEPURITI8  549 


PYELITIS.— PYELONEPHRITIS 


The  diet  in  these  conditions  should  be  very  bland  and  non-irritat- 
ing. The  substances  and  foods  previously  mentioned  as  irritating' 
should  all  be  avoided.  Milk,  buttermilk,  almond  milk,  and  the  like, 
should  form  the  bulk  of  the  diet.  Milk-toast,  gruels,  and  cereals  may 
also  be  given.  If  the  heart  is  strong,  an  abundance  of  fluid  may  be 
allowed  in  order  to  flush  out  tlie  kidneys ;  alkaline  mineral  waters  and 
flaxseed  tea  are  among  the  best  for  this  purpose.  Care  should  be 
taken  that  the  patient  receives  sufficient  protein  daily.  Increase  of 
diet  ma}'  be  made  along  the  same  lines  as  are  indicated  in  acute 
nephritis.  • 

RENAL  AND  VESICAL  CALCULI 

The  diet  as  a  cause  of  stone,  especially  of  the  uric  acid  variety,  has 
been  the  subject  of  much  controversy.  In  children  it  has  been  stated 
that  the  formation  of  stone  usually  follows  a  poor  and  insufficient 
milk  supply.  Ordinarily  it  may  be  said  that  too  rich  food,  too  large 
meals,  and  an  inactive  life  are  the  most  potent  causative  factors. 
Certain  individuals  are  prone  to  calculus-formation. 

The  following  suggestions  regarding  the  diet  will  be  found  useful : 
Forbid  strong  drinks,  and  all  alcohol  if  possible ;  much  meat,  and 
especially  the  nuclein-containing  meats,  as  thymus,  spleen,  liver, 
brain ;  caviare,  etc.,  smoked,  pickled  and  spiced  meats,  and  rich  foods 
in  general.  The  fats  and  sugars,  as  well  as  the  cereals,  should  be 
restricted.  The  diet  should  be  made  up  of  the  plainer,  well-prepared 
foods,  and,  as  far  as  possible,  a  vegetable  diet  should  be  prescribed. 
"Water,  especially  the  alkaline  mineral  waters,  may  be  allowed  in 
abundance.  When  alkaline  mineral  waters  are  given  for  acid  stones, 
they  should  be  used  only  so  long  as  the  urine  remains  acid.  If  it 
becomes  alkaline,  the  waters  should  be  discontinued,  lest  phosphates 
be  deposited  on  existing  stones. 

LITHEMIA.— THE  SO-CALLED  URIC-ACID  DIATHESIS 

The  factors  in  the  causation  of  this  disease  are  heredity,  a  too 
abundant  and  a  too  rich  diet,  and  an  inactive  life.  It  may  be  re- 
garded as  an  irregular  form  of  gout.  At  present  the  views  concern- 
ing its  pathology  are  too  diverse  and  numerous  to  deserve  comment. 
The  condition  is  usuallj^  manifested  by  migraine,  neuralgia,  sick  head- 
ache, skin  eruptions,  and  the  like. 

The  diet  is  the  principal  factor  in  the  treatment,  and  scarcely  of 
less  importance  are  fresh  air  and  exercise.  It  is  more  common  among 
the  well-to-do  in  winter,  for  out-of-door  life  in  summer  usually  means 
more  or  less  nearly  perfect  metabolism. 

The  diet  should  be  similar  to  that  outlined  elsewhere  for  the  gouty, 
A  reduction  in  the  quantity  of  food  taken,  especially  of  the  protein 
supply,  and  an  avoidance  of  alcohol  and  rich,  complex  foods  are  the 
principal  indications.     (See  Gout.) 


550  DIET  ly  DLSEASE 

GONORRHEA 

The  diet  in  this  disease  is  of  considerable  importance.  Improper 
food  and  drink  not  only  serve  to  prolong  the  disease,  but  overin- 
dulgences  in  forbidden  articles  may  cause  a  return  of  the  discharge 
even  after  the  disease  has  apparently  been  cured. 

The  directions  for  diet  are  very  simple.  All  irritating  foods  and 
drinks  should  be  avoided,  as  should  all  indigestible  articles.  The  diet 
should  consist  of  plain  and  wholesome  food.  Where  it  is  possible, 
skim-milk  should  form  the  basis  of  the  diet.  Too  much  meat  should 
not  be  taken,  and  twice-cooked  meats  and  fried  and  very  greasy 
foods  avoided  as  far  as  possible.  Carbohydrates,  as  breadstuffs, 
cereals,  and  the  non-acid  vegetables,  may  be  allowed.  Care  should 
be  taken  to  avoid  all  complicated  and  highly  seasoned  foods,  all 
pepper,  spices,  and  salad  dressings.  In  a  word,  everything  previously 
mentioned  as  irritating  to  the  genito-urinary  tract  should  be  avoided. 
Acid  fruits,  asparagus,  and  tomatoes  are  also  to  be  forbidden.  Tea 
and  cofifee  should  be  prohibited  or  given  very  weak  and  well  diluted 
with  milk  or  cream.  All  alcoholic  drinks  should  be  forbidden.  When 
the  patient  must  drink,  in  order  to  avoid  suspicion,  claret  has  been 
recommended  as  least  irritating,  but  even  this  is  best  avoided. 

An  abundance  of  plain  or  effervescing  water  should  be  taken,  but 
not  in  sufficient  quantities  to  disturb  digestion.  It  is  best  to  drink  the 
water  between  meals  and  on  an  empty  stomach.  Flaxseed  tea  and 
similar  demulcent  drinks  may  be  helpful. 

Tobacco  may  be  allowed  habitues,  but  not  in  excess.  Moderate 
smoking  in  those  accustomed  to  the  habit  is  regarded  as  beneficial 
rather  than  as  harmful. 

DIET  IN  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  necessity  for  the  correct  management  of  the  diet  in  nervous 
diseases  is  becoming  appreciated  more  and  more  every  year.  As  a 
general  rule  it  may  be  stated  that  all  functional  diseases  attended 
with  emaciation  are  greatly  benefited,  if  not  entirely  relieved,  merely 
by  increasing  the  patient's  weight  by  such  methods  as  are  suggested 
under  the  heading  of  Rest  Cure.  Patients  with  chronic  organic 
lesions  will,  as  a  rule,  be  made  more  comfortable  if  the  following 
two  points  are  borne  in  mind.  First,  to  overcome,  so  far  as  possible, 
emaciation  and  anemia  where  the  nutrition  has  a  tendency  to  be 
below  normal ;  and,  secondly,  and  of  no  slighter  importance,  to  pre- 
vent undue  obesity  in  those  so  inclined,  particularly  where  there  is 
disturbance  of  locomotion.  A  patient  may  be  condemned  to  remain 
in  bed  or  in  a  chair  on  account  of  the  excessive  weight  which  his 
inactivity  has  fostered.  For  further  particulars  on  this  subject  the 
student  is  referred  to  the  section  on  Obesity. 


DIET  IX  DISEASES  OF  THE  NERVOUS  SYSTEM  551 

Most  patients  regard  diet  as  a  very  unimportant  part  of  the  treat- 
ment ;  this  is  true  especially  of  those  cases  that  most  need  careful 
feeding.  The  necessity  for  careful  dietary  should  be  impressed  upon 
these  patients,  and  a  faith  in  its  efficacy  engendered  where  the  dis- 
ease is  of  a  functional  nature. 

The  diet  suitable  in  nervous  diseases  has  been  the  subject  of  many 
diverse  opinions,  particularly  in  the  minds  of  the  laity.  Fish  has 
been  vaunted  as  a  "brain  food,"  and  various  fats  or  cereals  have  been 
suggested  for  nervous  conditions.  At  the  present  time,  it  may  be 
stated,  there  is  no  specific  "nerve  food."  The  nutrition  of  the 
nerv^ous  system  will  be  good  when  the  patient's  general  nutrition  is 
good,  and  vice  versa.  Both  in  functional  disorders  of  the  nervous 
system  and  in  the  psychoses  dependent  upon  exhaustion  the  improve- 
ment of  the  general  condition  should  be  the  first  care. 

The  basis  of  the  diet,  which  will  be  outlined  later,  is  usually  milk. 
Care  should  be  taken  to  see  that  the  patient  gets  sufficient  fluid,  and 
where  no  tendency  to  obesity  exists,  water  should  be  taken  with  eaeh 
meal  and  usually  at  bedtime  and  on  rising.  It  may  also  be  taken 
between  meals  if  desired.  When  there  is  disturbance  of  digestion,  it 
is  a  good  plan  to  prepare  the  stomach  for  the  meal  by  sipping  a  glass 
of  hot  water  on  rising  and  an  hour  or  less  before  each  meal.  The 
mineral  waters  may  be  used  when  desired;  the  alkaline  ones  are  apt 
to  be  of  most  value.  Carbonated  waters  should  be  used  with  care, 
lest  the  flatulence  they  may  cause  give  rise  to  symptoms  the  im- 
portance of  which  may  be  greatly  exaggerated  by  the  patient. 

A  question  of  great  importance  is  whether  or  not  alcohol  should 
be  used.  As  a  general  rule  it  should  not  be  allowed.  In  cases  with 
chronic  lesions,  where  the  patient  has  been  accustomed  to  the  use  of 
alcohol  all  his  life,  it  may  be  allowed,  if  not  otherwise  contraindicated, 
as  by  a  tendency  to  cerebral  hemorrhage,  arteriosclerosis,  chronic  in- 
terstitial nephritis,  and  the  like.  The  use  of  alcohol  in  the  functional 
disorders  is  usually  contraindicated. 

NEURALGIA 

Neuralgia  may  be  due  to  many  causes,  among  them  being  the 
various  diseases  that  affect  metabolism.  The  cause  of  the  neuralgia 
must  be  determined  before  a  suitable  diet  can  be  ordered.  The  fol- 
lowing are  among  the  most  frequent  causes :  anemia,  gout,  lithemia, 
rheumatism,  diabetes,  and  alcoholism.  The  diet  to  be  prescribed  is 
the  diet  suited  to  the  condition. 

Alcohol  is  a  frequent  cause  of  severe  neuralgias  often  simulating 
migraine.  The  quantity"  used  may  be  comparatively  trifling,  and 
the  patients  frequently  can  not  be  classed  as  alcoholics.  When  no 
other  cause  for  the  disease  is  found  all  alcohol  should  be  forbidden. 
In  the  cases  dependent  on  anemia  and  on  exhausted  condition*  alco- 


552  DIET  m  DISEASE 

hol  is,  however,  useful,  and  should  be  used  in  these  cases  to  improve 
the  nutrition,  and  not  for  the  temporarj^  feeling  of  well-being  or  for 
the  relief  of  pain,  which  it  may  in  reality  engender. 

Tea  and  coffee  should  be  forbidden  in  chronic  neuralgia  or  where 
there  are  frequent  attacks.  This  does  not,  however,  apply  to  attacks 
of  migraine  that  are  not  affected  by  coffee,  or  may  even  be  relieved 
by  a  cup  of  hot  strong  coffee  taken  as  the  attack  is  about  to  come  on. 

According  to  Gowers,  vegetarianism  may  be  a  cause  of  neuralgia. 
In  these  cases  the  addition  of  meat  to  the  diet  will  give  relief.  The 
converse  may  be  true,  especially  where  there  is  a  gouty  tendency,  the 
ingestion  of  too  much  meat  frequently  being  at  the  root  of  the  trouble. 
Care  and  experience  alone  will  help  in  deciding  whether  the  patient 
is  getting  too  much  food,  and  whether  his  diet  should  be  cut  down  and 
his  elimination  increased,  or  whether  the  case  is  dependent  on  an 
insufficient  or  improper  diet. 

As  a  general  rule,  plain  wholesome  food  should  be  ordered  at 
regular  intervals.  The  patient  should  not  be  allowed  to  eat  between 
meals.  All  rich,  complex,  and  highly  seasoned  foods  should  be  for- 
bidden, as  should  all  fried  foods,  pastry,  and  anything  known  to 
disagree  with  the  patient.  Care  should,  however,  be  taken  that  the 
diet  be  not  too  restricted,  for  the  patient's  ability  to  take  different 
articles  is  often  purely  imaginar^\  True  idiosjaicrasies  for  different 
articles  of  food  are  not  very  common.  The  excessive  use  of  tobacco 
may  be  the  cause  of  neuralgia. 

GASTRALGIA 

A  general  rule  may  be  made  in  these  cases  of  avoiding  excesses  in 
alcohol,  tea,  coff*ee,  sweets,  and  tobacco.  In  some  cases  the  taking  of 
food  increases  the  severity  of  the  attack.  The  existence  of  stomach 
disorders  should  be  carefully  determined,  and  if  there  is  no  apparent 
basis  for  the  trouble,  a  rest  cure  may  give  relief. 

There  are  other  cases  where  the  pain  comes  on  when  the  stomach 
is  empty.  (See  Diseases  of  the  Stomach.)  In  these  relief  is  often 
afforded  by  giving  a  cup  of  hot  milk  or  bouillon  with  a  biscuit 
(cracker)  in  the  middle  of  the  morning  and  afternoon,  and  at  night 
on  going  to  bed.  If  the  pain  begins  in  the  night  from  the  same 
cause,  a  glass  of  milk  should  be  kept  at  the  bedside,  and  when  the 
patient  is  awakened  by  the  pain,  he  may  take  a  few  sips  of  the  milk. 

VISCERAL  NEURALGIA 

When  this  is  not  relieved  by  ordinars^  means,  the  patient  should 
be  put  to  bed  and  kept  on  a  milk  diet.  Repeated  examinations  should 
be  made  to  determine  the  exact  cause  of  the  trouble.  Many  of  these 
cases,  where  no  cause  can  be  assigned,  are  relieved  by  rest  and  a 
milk  diet. 


DIET  IX  DISEASES  OF  THE  NERVOUS  SYSTEM  553 

MIGRAINE 

Migraine,  or  sick  headache,  as  it  is  popularly  termed,  should  not 
be  confused  with  ordinary  neuralgia.  The  diagnosis  may  at  times  be 
somewhat  difficult.  ]\Iucli  can  be  done  to  lessen  the  frequency  of 
the  attacks,  but  any  attempt  entirely  to  overcome  them  has  thus  far 
proved  fruitless.  Open-air  life  of  a  vigorous  kind  probably  does 
more  good  than  anything  else,  but  most  of  the  sutferers  from  migraine 
find  this  impractical  to  carry  out.  The  life  of  the  patient  should 
be  regulated  carefully.  Sufficient  sleep  should  be  obtained  and  late 
hours  avoided.  The  food  should  be  plain  and  wholesome,  and  taken 
at  regular  intervals,  and  eating  between  meals  should  be  discoun- 
tenanced. Outdoor  exercise  should  be  insisted  upon  wherever  possi- 
ble.    Excesses  of  all  kinds  must  studiously  be  avoided. 

It  may  be  mentioned  that  sufferers  from  migraine  are  apt  to  attri- 
bute the  cause  of  the  attack  to  some  article  of  food.  This  is  not 
likely  to  be  the  case,  and  the  patient  should  not  be  allowed  to  cut 
ofiC  first  one  and  then  another  necessary  article  from  his  diet.  Starch 
indigestion  is  present  in  some,  and  should  receive  careful  attention. 
These  patients  occasionally  get  along  best  on  a  diet  that  is  largely 
vegetarian,  but  this  is  not  so  in  all  cases.  Coffee  need  not  be  pro- 
hibited, for,  as  a  rvile,  it  is  not  the  cause  of  the  trouble,  and  in  some 
instances,  when  taken  at  the  outset  of  an  attack,  it  may  even  afford 
relief. 

INSOMNIA  AND  DISTURBED  SLEEP 

When  not  dependent  upon  other  conditions,  these  are  apt  to  be 
due  either  to  eating  at  night  or  to  a  depressed  state  of  the  nutrition. 
For  the  first  there  is  nothing  to  do  but  to  discontinue  the  habit  of 
eating  at  night.  There  are  but  few  persons  who  reach  middle  age 
and  who  can  eat  late  at  night  with  impunity,  and  sooner  or  later  the 
individual  learns  that  he  must  give  up  the  habit.  There  are  some, 
however,  with  whom  the  practice  seems  to  agree. 

"When  the  trouble  is  caused  by  malnutrition  or  anemia,  the  general 
condition  of  the  patient  must  be  treated.  Good  food,  regular  hours, 
milk,  or  some  light  food  between  meals,  and  on  going  to  bed  a  cup 
of  hot  milk,  cocoa,  or,  if  preferred,  beef-tea,  malted  milk,  or  similar 
preparation  may  be  ordered. 

In  many  cases  where  the  nutrition  is  fairly  good  one  of  the  hot 
drinks  just  mentioned  taken  at  bedtime  may  be  all  that  is  necessary. 
This  is  especially  true  of  the  insomnia  and  disturbed  sleep  that  follow 
the  doing  of  mental  work  at  night.  The  effect  is  to  dilate  the  ab- 
dominal vessels  and  to  restore  the  equilibrium  of  the  circulation.  A 
brisk  walk  in  the  open  air  or  five  minutes'  exercise  will  often  ac- 
complish similar  results. 

In  the  aged  and  the  weak  a  "night-cap,"  in  the  form  of  a  small 
glass  of  brandy  or  whisky,  or  a  hot  toddy,  is  acceptable  and  secures  a 


554  DIET  IX  DISEASE 

good  night's  rest.     This  should,  however,  be  discountenanced  in  the 
young  and  vigorous. 

VERTIGO 

There  are  so  manj^  forms  of  vertigo,  and  it  arises  from  so  many 
widely  different  causes,  that  it  must  not  be  forgotten  that  a  very 
common  cause  is  in  a  disordered  digestion.  Indigestion  from  what- 
ever cause  may  give  rise  to  it,  and  the  eating  of  certain  irritating 
foods,  such  as  shell-fish,  crabs,  lobsters,  and  the  like,  may  occasionally 
bring  on  an  attack,  particularly  in  those  unaccustomed  to  their  use. 
Insufficient  food  may  also  be  a  cause.  All  causes  of  vertigo  require 
careful  study  before  a  definite  opinion  as  to  their  cause  is  given. 

EPILEPSY 

Epilepsy  bears  an  important  relation  to  diet.  There  is  no  specific 
"anti-epilepsy"  diet,  and  there  is  no  form  of  food  that  can  be  as- 
signed as  a  cause  of  epilepsy;  it  is,  however,  a  fact,  that  where  the 
diet  is  carefully  regulated  the  number  of  attacks  are  usually  les- 
sened. This  is  particularly  true  of  children.  The  principle  in- 
volved is  to  give  only  as  much  food  as  the  patient  can  easily  digest 
and  assimilate,  and  to  allow  sufficient  time  to  elapse  between  feedings 
for  him  to  utilize  and  excrete  the  end-products  of  what  he  does 
assimilate.  When  this  is  not  done,  attacks  maj"  be  provoked  by  irri- 
tating substances  in  the  bowel,  by  the  absorption  of  toxic  substances 
from  the  intestinal  tract,  or  by  the  accumulation  of  the  products  of 
metabolism  in  the  body.  In  the  epileptic  colonies  no  especial  diet  is 
used,  but  the  amount  and  the  variety  of  food  are  so  regulated  as  to 
secure  the  best  results.     (See  Craig  Colony  Dietary.) 

In  children  a  diet  composed  largely  of  milk  with  the  addition  of 
cereals  and  fruit,  is  most  useful.  In  older  persons  this  diet  is  not 
feasible  except  occasionally  as  a  temporary  measure.  For  these  latter 
meat  should  be  allowed  only  once  a  day,  unless,  on  account  of  ex- 
cessive manual  labor  or  because  of  a  weakened  condition  of  nutrition, 
the  patient  especially  demands  it.  Milk,  cereals,  bread,  vegetables, 
and  fruit  should  make  up  the  rest  of  the  dietary.  Each  patient 
should  be  instructed  to  take  only  digestible  food,  to  take  his  meals 
regularly,  and  not  to  eat  too  much.  They  should  also  be  taught  to 
eat  slowly  and  masticate  the  food  well.  The  avoidance  of  consti- 
pation is  of  primary  importance,  and  this  can  usually  be  secured  by 
the  proper  use  of  fruits,  and  the  coarser  forms  of  cereals. 

A  diet  free  from  sodium  chlorid  with  sodium  bromid  substituted  is 
of  considerable  value  in  the  treatment  of  epilepsy.  The  effect  is  more 
noticeable  in  the  petit  mal  than  in  grand  mal,  but  in  both  there  is  a 
decrease  in  the  number  of  seizures.  The  effect  of  this  treatment 
varies  in  different  individuals.  German  and  French  observers  report 
remarkable  results,  but  these  have  not  been  obtained  in  the  United 
States,  although  there  seems  to  be  little  question  of  the  value  of  the 


I 


DIET  IX  DISEASES  OF  THE  yERVOUS  SYSTEil  555 

treatment.  In  some  patients  the  withdrawal  of  sodium  chlorid  pro- 
duces untoward  ett'ects,  and  these  are  more  liable  to  occur  when  the 
bromid  is  not  substituted.  The  salt-free  diet  is  to  be  regarded  as  an 
adjunct  to  the  bromid  treatment.  When  the  regime  is  badly  borne 
there  are  dizziness,  headache,  weakness  of  the  legs,  loss  of  memory, 
edema,  diarrhea,  and  often  marked  mental  symptoms  with  a  teiidencj' 
to  melancholia.  There  may  be  a  marked  loss  of  appetite,  which  may 
lead  to  a  marked  aversion  for  food.  Some  of  Voisin's  patients  had 
to  be  forcibly  fed.  Sometimes  the  withdrawal  of  salt  causes  irrita- 
bility in  the  young,  and  may  rouse  the  indolent  to  activity. 

Quiet,  open-air  life,  pleasant  occupation  of  a  non-strenuous  kind, 
an  absence  of  worry,  and  agreeable  forms  of  recreation  are  just  as 
important  as  the  diet  in  these  cases. 

CHOREA 

In  chorea  the  diet  is  often  of  the  greatest  importance ;  this  is  espe- 
cially true  when  it  occurs  in  anemic  or  debilitated  children.  Rest 
and  an  easily  assimilable  diet  are  the  indications.  The  authors  are  of 
the  opinion  that  absolute  rest  in  bed,  if  possible  isolated  from  the 
remainder  of  the  family  and  under  the  care  of  a  trained  nurse,  who 
should  be  a  stranger,  combined  with  a  milk-diet  or  a  diet  composed 
largely  of  milk,  will  give  better  and  more  lasting  results  than  any 
other  form  of  treatment.  If  the  patient  is  anemic,  beef-juice  made 
from  fresh  beef  may  be  used  to  advantage,  as  well  as  raw  scraped 
beef  and  similar  foods.     (See  Anemia.) 

APOPLEXY 

The  Comatose  Slage. — During  the  early  stage  of  the  comatose  con- 
dition— i.  e.,  for  the  first  daj"  or  two — there  is,  as  a  rule,  no  necessity 
for  giving  the  patient  any  food.  As  the  disease  is  most  likely  to 
occur  in  obese,  overfed  individuals,  the  abstinence  from  food  is  often 
beneticial.  The  intestinal  tract  should  be  flushed  out  as  soon  after 
the  patient  is  seen  as  is  practicable.  Those  about  the  patient  should 
be  instructed  carefully  as  to  the  dangers  of  attempting  to  feed  the 
patient  if  he  is  unable  to  swallow,  for  he  may,  on  the  one  hand,  choke, 
and,  on  the  other,  he  may  draw  food  or  drink  into  his  lungs  during 
inspiration,  and  so  set  up  a  pneumonia. 

If  the  patient  is  in  need  of  nourishment  or  of  fluid,  it  may  be  given 
by  the  rectum.  Normal  salt  solution  may  be  given  by  the  rectum  to 
supply  the  body  with  fluid,  but  it  should  not  be  given  in  too  large 
quantities.     (See  Rectal  Feeding.) 

The  Later  Stages. — As  soon  as  the  patient  recovers  sufficiently  to 
be  able  to  swallow  without  danger  of  inspiring  the  food,  he  may 
be  fed  b}'  the  mouth.  The  food  should  be  liquid  or  semi-solid,  and  of 
a  bland,  unstimulating  character.  The  quantity  should  not  be  too 
large.     Milk,  milk  and  eggs  beaten  together  in  the  form  of  a  milk- 


556  DIET  IN  DISEASE 

punch,  without,  however,  the  addition  of  a  stimulant,  broths,  soft 
eggs,  and  milk  thickened  with  cereals,  or  the  purees  of  vegetables 
may  be  used.  As  the  patient  improves  other  food  may  be  added, 
but  the  diet  should  be  light,  easily  digestible,  and  as  non-stimulating 
as  possible.  The  patient  should  be  warned  against  overeating  and 
also  against  drinking.  Alcohol  is  allowable  only  in  the  case  of 
habitues  who  are  threatened  with  collapse  unless  it  is  used,  or  in  the 
same  class  where  food  is  not  assimilated  without  it.  It  should  al- 
ways be  given  in  moderate  amounts,  and  the  dosage  arranged  by 
the  physician,  and  never  left  to  the  nurse,  the  patient,  or  the  family. 

On  account  of  the  lack  of  exercise  the  diet  should  contain  but 
little  meat,  but  cereals,  vegetables,  and  fruit  should  be  given  in  small 
quantities  at  a  time,  and  as  evenly  distributed  throughout  the  day  as 
possible,  to  avoid  overfilling  of  the  vessels. 

The  greatest  danger,  from  a  dietary  standpoint,  is  in  those  patients 
who  recover  sufficiently  to  return  to  their  ordinary  modes  of  living. 
They  should  be  very  carefully  instructed  neither  to  drink  to  excess 
nor  to  overeat.  A  full  meal  and  several  drinks  may  be  the  cause  of 
a  second  or  of  a  fatal  attack.     (See  High  Blood-pressure.) 

DIET  IN  VARIOUS  TOXIC  CONDITIONS 
CHRONIC  MORPHIN  POISONING 

In  the  treatment  of  the  morphin  habit  the  diet  is  of  great  im- 
portance. A  good  plan  is  to  institute  the  rest  treatment  and  to 
give  the  patient  as  much  food  as  possible.  This  method  has  the 
additional  advantage  that  the  patient  is  kept  under  better  control  if 
the  nurse  can  be  trusted;  and  none  but  one  of  the  highest  character, 
who  cannot  be  bribed,  should  be  employed. 

In  obese  women  who  have  formed  the  morphin  habit — and  many 
women  who  use  the  drug  are  apt  to  take  on  flesh — rest  in  bed,  with  a 
milk  diet,  massage,  and  electricity,  may  be  of  great  service. 

ALCOHOLISM 

The  mild  forms  of  alcoholism  are  usually  easily  managed.  So  long- 
as  the  stomach  is  irritable  it  should  be  given  absolute  rest.  If  possi- 
ble, alcohol  should  be  withheld  entirely.  As  soon  as  the  stomach 
will  retain  fluid,  a  saline  mineral  water  or  a  saline  purge  should  be 
given.  jMilk  or  bouillon  is  next  to  be  prescribed,  and,  as  the  desire 
for  food  returns,  a  light  diet  of  soft-boiled  eggs,  milk-toast,  and  the 
like  should  be  allowed.  After  recovery  all  rich  and  highly  seasoned 
food  should  be  avoided,  particularly  the  spices  and  peppers,  which 
are  commonly  used  to  excess. 

In  the  severe  forms  the  diet  should  be  that  recommended  for 
chronic  gastritis.  Some  confirmed  alcoholics  can  retain  nothing  in 
the  stomach  until  they  have  had  their  morning  drink.     When  nutri- 


i 


DIET  IN  VARIOUS  TOXIC  COyOITIONS  557 

tion  is  threatend,  this  may  be  allowed,  but  it  is  apt  to  lead  to  excesses 
later  in  the  day. 

Ill  the  very  severe  forms,  as  in  delirium  tremens  or  in  cases 
approaching  it,  the  patient  should  take  as  much  fluid  as  possible 
to  flush  out  the  system  and  the  intestinal  tract  should  be  thoroughly 
purged.  The  food  should  be  given  in  a  predigested  or  in  a  partially 
predigested  form,  and  at  frequent  intervals.  In  this  way  the  crav- 
ing for  drink  is  somewhat  alleviated.  Bouillon  or  beef-tea  to  which 
considerable  amounts  of  black  pepper  or  even  Cayenne  pepper  have 
been  added  is  useful  in  this  condition,  although  their  use  would  be 
contraindicated  for  any  but  an  alcohol-saturated  person.  Rest  and 
suralimentation  as  soon  as  food  can  be  borne  constitute  the  best 
method  of  managing  these  cases.  Strychnin  may  be  used  as  a  stimu- 
lant, and  belladonna  in  large  doses  is  of  service. 

Illness  or  Injury  in  Alcoholics. — When  a  man  who  has  been 
accustomed  to  taking  several  glasses  of  liquor  every  day  for  years  is 
suddenly  stricken  ill  or  injured,  delirium  will  often  develop  if  the 
stiumulant  is  rapidly  withdrawn.  In  all  such  cases  the  accustomed 
amount  of  alcohol  should  be  given,  care  being  taken,  however,  to  pre- 
vent overindulgence. 

In  alcoholics  affected  with  pneumonia  alcohol  is  necessary  to 
sustain  life.  When  delirium  occurs  in  the  course  of  pneumonia,  alco- 
hol should  be  ordered,  although  in  ordinarj%  uncomplicated  cases  of 
delirium  tremens  due  to  extreme  overindulgence  it  should  be  with- 
held. 

CHRONIC  LEAD  POISONING 

In  this  slate  especial  efifort  should  be  made  to  ascertain  the  cause, 
and  where  the  condition  is  due  to  the  handling  of  lead,  frequent 
washing  of  the  hands  and  cleansing  of  the  finger-nails,  particularly 
before  eating,  should  be  advised. 

Oliver  states  that  abstinence  from  alcohol  serves  as  a  preventive, 
and  advocates  that  a  substantial  meal  be  taken  before  beginning 
work.  Constipation  is  to  be  overcome  by  dietetic  or  medicinal  means. 
Water  should  be  drunk  freely,  and  lemonade  containing  diluted  sul- 
phuric acid  or  aromatic  sulphuric  acid  is  advised  as  a  prophylactic 
drink.  Ten  or  fifteen  drops  of  the  acid  may  be  added  to  a  glass  of 
w^ater.  Milk  is  also  drunk  as  a  preventive  by  the  workers  in  factories, 
but  is  probably  of  use  chiefly  as  a  diuretic  and  for  maintaining  the 
nutrition. 

THE  WEIR-MITCHELL  REST  CURE 

In  his  little  book.  Fat  and  Blood,  destined  to  be  one  of  the  classics 
of  medicine.  Weir  Mitchell  has  given  us  the  technic  of  his  "rest 
cure,"  which  has  been  used  so  successfully  in  the  treatment  of  cer- 
tain cases  of  nervous  exhaustion.     Others  have  made  suggestions,  and 


558  DIET  IN  DISEASE 

Playfair,  Leyden,  Keating,  and  others  have  given  directions,  and 
diet-lists,  but  they  differ  but  little  from  those  of  Mitchell,  and  are 
not  nearly  so  satisfactory.  A  careful  reading  of  this  book  is  recom- 
mended, for  nothing  beyond  the  essentials  of  the  treatment  can  be 
given  here. 

Mitchell  defines  the  cure  as  a  "certain  method  of  reviving  the 
vitality  of  feeble  people  by  a  combination  of  entire  rest  and  excessive 
feeding,  made  possible  by  passive  exercise  obtained  through  steady 
use  of  massage  and  electricity." 

The  treatment  is  applicable  to  many  forms  of  nervous  exhaustion, 
but  particularly  to  nervous  women  who  have  lost  weight, — as  Mitchell 
says,  ' '  those  who  are  thin  and  lack  blood. ' ' 

Before  beginning  this  treatment  it  is  important  to  ascertain 
whether  the  patient  "is  losing  or  has  lost  flesh,  is  by  habit  thin  or 
fat."  In  those  who  have  become  emaciated  as  a  result  of  disease  a 
thinning  of  the  blood  occurs  at  the  same  time,  and  as  the  patient 
recovers  the  former  body-weight,  the  blood,  as  a  rule,  becomes  richer. 
There  are  certain  anemic  fat  persons  who  require  individual  con- 
sideration. (See  Obesity.)  In  fat,  nervous  patients  the  treatment 
is  of  little  benefit,  as  it  tends  to  increase  the  accumulation  of  fiesh ; 
if  other  circumstances  allow,  these  cases  are  better  treated  by  a  re- 
duction cure,  as  detailed  in  another  section.  Those  who  derive  most 
benefit  from  this  treatment  are  patients  that  have  lost  flesh.  The 
cure  is  indicated  in  nervous,  exhausted  conditions,  and  in  certain 
other  diseases  in  which  the  patient  has  lost  flesh.  In  the  very 
earliest  stages  of  pulmonary  tuberculosis  this  treatment,  combined 
with  an  abundance  of  fresh  air,  is  of  benefit.  For  dyspeptics,  cases 
of  chronic  malaria  poisoning,  and  the  like,  it  may  also  be  recom- 
mended. In  short,  in  any  condition  in  which  there  are  Avasting  and 
anemia,  whether  or  not  emotional  disturbance  is  present,  the  rest 
cure  will  be  found  useful.  Women  are  better  subjects  for  this  treat- 
ment than  are  men,  as  the  latter  are  less  able  to  endure  the  isolation. 
In  women  who  are  thin  and  anemic  and  who  complain  of  being  tired 
constantly,  the  cure  is  of  the  greatest  service.  These  women  become 
exhausted  out  of  all  proportion  to  the  amount  of  exercise  they  take, 
and  the  "tire"  shows,  as  Mitchell  puts  it.  In  some  cases  nausea  or 
diarrhea  may  even  follow  exertion. 

While  the  cure  usually  succeeds  in  properly  selected  cases,  Mitchell 
states  that  in  certain  cases  failure  results  from  what  he  aptly  terms 
"an  unconquerable  taste  for  invalidism,"  from  "sheer  laziness,"  or 
in  those  cases  "to  whom  the  change  of  moral  atmosphere  is  not  brac- 
ing." 

The  method  is  more  likely  to  succeed  and  is  easier  to  conduct  in 
severe  cases  than  in  mild  cases.  Playfair  speaks  of  "the  half -ill  who 
constitute  the  difficult  cases."  Organic  disease  is  a  contraindica- 
tion, but  there  are  certain  conditions  that  are  benefited  by  it.     Heart 


THE  WEIR-MITCHELL  REST  CURE  559 

disease  with  ruptured  compensation  and  the  irritable  heart  of  exoph- 
thalmic goiter  are  both  suitable  conditions  for  this  treatment.  Many- 
uterine  and  ovarian  disorders  are  cured  by  it,  rendering  operation 
unnecessary,  and  those  cases  that  have  been  operated  upon  without 
bringing  relief  may  often  be  restored  to  health. by  this  method  of 
treatment.  Floating  kidne}',  as  mentioned  elsewhere,  is  a  suitable 
condition,  if  the  case  is  a  recent  one,  for  the  rest  treatment.  Certain 
forms  of  mental  disturbance  are  greatly  benefited  by  it,  and  the 
method  of  forced  feeding  of  the  insane  is  but  an  example  of  this 
method  of  treatment.  Melancholia  with  periods  of  agitation  is  often 
benefited  by  several  weeks'  quiet  and  proper  feeding  when  the  agita- 
tion comes  on. 

The  technic  of  the  treatment  is  explained  in  a  most  interesting 
way  by  JMitchell,  and  the  following  details,  largely  condensed,  are 
taken  from  his  book.  The  more  nearly  perfect  the  technic  and  the 
more  closely  it  is  adhered  to,  the  more  likely  is  cure  to  follow.  The 
cases  are  of  various  grades  of  severity,  and  the  treatment  should  be 
modified  to  suit  the  individual. 

Isolation  is  necessary,  and  the  patient  should  be  removed  to  a 
hospital  or  a  sanitarium,  away  from  familiar  scenes.  Home  treat- 
ment does  not  succeed  well.  If  circumstances  compel  the  patient  to 
remain  at  home,  her  room  should  be  changed.  In  severe  cases  wi*th 
emotional  manifestations  visiting  is  forbidden,  but  it  may  be  allowed 
to  a  "certain  extent  where  the  patient  is  anemic  owing  to  a  distinct 
cause,  as  overwork,  blood-losses,  dyspepsia,  low  fevers,  or  nursing." 

The  nurse  should  be  a  stranger  to  the  patient,  and  if  for  any 
reasbn  the  patient  does  not  get  along  with  the  nurse,  another  nurse 
should  be  secured.  She  should  be  a  strong,  healthy,  firm  woman, 
with  tact  and  sufficiently  attractive  qualities.  The  family  should 
not  be  allowed  to  nurse  the  patient,  for,  as  0.  W.  Holmes  says,  "the 
hysterical  girl  is  a  vampire  who  sucks  the  blood  of  the  healthy  people 
about  her." 

Communication  with  friends  and  family  should,  as  a  rule,  be  cut 
off  entirely,  and  not  even  the  reading  of  letters  should  be  allowed. 
After  several  weeks,  if  the  patient  is  improving,  she  may  be  allowed 
to  read  the  newspaper  each  day. 

Rest  is  a  most  important  feature,  and,  as  a  rule,  the  patient  should 
be  put  to  bed  for  six  weeks  or  two  months. 

In  other  cases,  especially  where  the  p-atient  is  not  able  to  undergo 
the  regular  treatment,  as  in  dispensary  cases,  a  modified  rest  cure 
may  be  tried.  The  following  is  Mitchell's  schedule  for  such  cases; 
this  may  be  modified  according  to  circumstances : 

"7.30  A.M.:  Cocoa,  coffee,  hot  milk,  beef  extract,  or  hot  water. 
Bath  (temperature  stated).  Rough  rub  with  towel  or  flesh-brush. 
Bathing  and  rubbing  may  be  done  by  attendant.  Lie  down  a  few 
minutes  after  finishing. 


560  DIET  IN  DISEASE 

"8.30  A.M.:  Breakfast  in  bed.  (Details  as  to  diet.  Tonic,  aperi- 
ent, malt  extract  as  ordered.)  May  read  letters,  papers,  etc.,  if  eyes 
are  good. 

"10-11  A.M.:  Massage  if  required  is  usually  ordered  one  hour 
after  breakfast,  or  Swedish  movements  are  given  at  that  time.  An 
hour's  rest  follows  massage.  Less  rest  is  needed  after  the  move- 
ments.    (Milk  or  broth  after  massage.) 

"12  M. :  Rise  and  dress  slowly.  If  gymnastics  or  massage  are  not 
ordered,  may  rise  earlier.  May  see  visitors,  attend  to  household 
affairs,  or  walk  out. 

"1.30  A.M.:  Luncheon.  (Malt,  tonic,  etc.,  ordered.)  In  invalids 
this  should  be  the  chief  meal  of  the  day.  Rest,  lying  down,  not  in 
bed,  for  an  hour  after. 

"3  P.M.:  Drive  (use  street  cars  or  walk)  one  to  two  and  one-half 
hours.     (Milk  or  soup  on  return.) 

"7  P.M.:  Supper.     (Malt,  tonic,  etc.,  ordered,  detail  of  diet.) 

"10  P.M.:  Hot  milk  or  other  food  at  bedtime." 

This  may  be  altered  by  omitting  the  out-door  exercise  in  invalids 
or  for  business  men  who  can  rest  only  part  of  the  time  by  conducting 
their  business  in  the  morning,  utilizing  the  afternoon  for  massage 
and  rest.  If  massage  is  not  ordered,  no  expense  is  attached  to  this 
routine. 

In  extreme  eases  the  patient  is  made  to  rest  absolutely.  No  exer- 
tion of  any  kind  is  to  be  allowed.  The  bed-pan  is  to  be  used  with  the 
patient  in  the  recumbent  position.  She  should  be  removed  to  a  couch 
for  an  hour,  both  morning  and  evening,  while  the  bed  is  bjeing  fresh- 
ened. The  patient  should  be  fed,  and  later,  when  allowed  to  feed 
herself,  the  meat  should  be  cut  up  for  her.  A  sponge-bath  should  be 
given  daily,  but  if  it  causes  depression,  it  may  be  given  less  fre- 
quently. After  two  weeks,  if  it  is  thought  desirable,  the  patient  may 
be  read  to  for  one  to  three  hours.  The  monotony  of  the  treatment  is 
not  so  trying  as  would  be  imagined,  for  the  routine  of  the  day 
occupies  most  of  the  time.  An  important  part  of  the  treatment  is 
the  moral  suasion,  and  when  no  good  can  be  attained  in  this  direction, 
the  physician  should  judiciously  seek  to  lead  the  thoughts  of  his 
patient  to  the  selfishness  of  the  life  previously  led.  The  nurse  and 
masseuse  should  not  be  allowed  to  talk  about  or  to  listen  to  the  pa- 
tient's ills,  and  she  should  be  taught  that  she  must  speak  of  them 
only  to  the  physician. 

Massage  and  electricity  are  resorted  to  in  order  to  maintain  nutri- 
tion and  circulation  while  at  rest.  Mitchell  gives  minute  instruc- 
tions regarding  both.  General  massage  of  the  whole  body  is  to 
be  given,  care  being  taken  not  to  excite  pain  by  manipulating  tender 
areas.  The  tapping  movements,  slapping,  and  the  like  are  not  to 
be  used  in  nervous  patients.     Care  should  be  exercised  to  avoid  pro- 


THE  WEIR-MITCHELL  REST  CURE  561 

ducing-  sexual  excitement ;  this  may  be  aroused  in  both  sane  and 
insane  patients  from  friction  near  the  genitals  or  over  the  back  or 
buttocks.  If  it  does  occur,  the  operator  should  avoid  the  sensitive 
areas.  In  the  average  case  massage  should  be  given  for  an  hour 
daily  for  about  six  weeks,  and  then  on  each  alternate  day.  The 
time  chosen  for  this  should  be  about  midway  between  meals.  Care 
should  be  taken  to  keep  the  parts  warmed  by  the  massage  well 
covered. 

The  same  precautions  should  be  taken  in  using  electricity  as  when 
giving:  massage.  The  induced  current  should  be  used,  and  it  is  well 
to  employ  a  battery  in  which  the  breaks  are  very  slow — from  two 
to  five  seconds.  The  more  rapid  interruptions  are  useful,  however, 
but  in'  the  hands  of  an  unskilful  operator  may  excite  pain  and  ap- 
prehension in  the  patient.  The  poles  may  be  placed  four  or  five 
inches  apart  on  the  muscle,  and  the  whole  bod}^  should  be  gone  over. 

The  diet  is  one  of  suralimentation.  In  many  cases  milk  should 
form  the  basis  of  the  diet  at  first.  Karell's  method  of  administration 
is  to  be  used.     (See  Milk  Cure.) 

If  those  patients  who  are  obese,  anemic,  and  nervous  (or  even 
when  they  are  not),  in  whom  the  other  methods  of  reduction  are  of 
no  value,  a  reduction  secured  by  means  of  rest  and  a  milk  diet  often 
succeeds.  The  milk  may  be  skimmed  if  necessary.  The  patient  is 
put  to  bed  and  placed  on  a  milk  and  general  diet  and  then  on  an 
exclusive  milk  diet.  Massage  and  electricity  are  employed,  and  the 
patient's  weight  is  noted.  If  it  does  not  decrease,  the  amount  of 
milk  is  decreased  to  three  pints  or  even  to  a  quart  a  day  until  the 
weight  has  fallen  to  the  desired  number  of  pounds.  The  diet  is 
then  gradually  increased  and  the  patient  by  degrees  allowed  to  go 
about.  Directions  for  the  future  diet  must  be  given ;  this  should  be 
alon^'  the  lines  laid  down  in  the  section  on  Obesity. 

In  thin,  anemic,  exhausted  women,  who  are  the  ones  usually  treated, 
the  diet  is  as  follows :  The  patient  is  put  to  bed  and  the  diet  gradu- 
ally changed  from  the  ordinary  diet  to  a  milk  diet.  This  is  done  by 
giving  from  three  to  four  ounces  of  milk  every  two  hours,  after  the 
Karell  method.  Then  the  patient  is  given  two  quarts  of  milk  in 
each  twenty-four  hours.  The  amount  is  divided,  and  a  portion  given 
at  three-hour  intervals.  At  the  end  of  the  first  week  a  pound  of 
beef  is  administered  in  the  form  of  a  raw  soup.  This  is  given  three 
times  a  day,  one  pound  of  beef  being  used  each  day.  If  desired,  this 
may  be  replaced  by  peptonized  food.  (See  formulas  in  the  Appen- 
dix.) 

After  ten  days  three  meals  a  day  are  given.     These  are  led  up  to 

gradually,  and  the  patient  is  kept  on  the  milk  diet  until  the  stomach 

feels  comfortable.     Then,  usually  within  from  four  days  to  a  week, 

a  light  breakfast  is  allowed,  and  in  a  few  days  more  a  chop  is  given 

36 


562  DIET  IN  DISEASE 

at  the  midday  meal.  After  a  short  time  the  patient  is  given  three 
full  meals,  together  with  three  or  four  pints  of  milk  instead  of  water, 
either  with  or  after  the  meals. 

After  about  ten  days  of  this  treatment  from  two  to  four  ounces 
of  a  good  fluid  extract  of  malt  are  given  before  each  meal.  "As  to 
meals,  I  leave  them  to  the  patient's  caprice,  unless  this  is  too  un- 
reasonable; but  I  like  to  give  butter  largely,  and  have  little  trouble 
in  having  this  most  wholesome  of  fats  taken  in  large  amounts,  A 
cup  of  cocoa  or  of  coffee  and  milk  on  waking  in  the  morning  is  a 
good  preparation  for  the  fatigue  of  the  toilet." 

In  some  of  the  difficult  cases  half  an  ounce  of  cod-liver  oil  is  given 
half  an  hour  after  each  meal.  If  it  causes  nausea  or  interferes  with 
the  appetite,  it  is  given  as  a  rectal  injection.  This  is  of  particular 
service  where  the  bowels  are  sluggish.  It  may  also  be  given  in  the 
form  of  an  emulsion  with  pancreas  extract.  In  some  it  acts  admira- 
bly; in  others  it  may  cause  tenesmus. 

Alcohol  is  not  necessary  to  the  treatment,  and,  as  a  rule,  is  omitted, 
although  a  small  amount  helps  in  the  accumulation  of  fat.  It  should 
always  be  used  with  great  care  and  judgment.  In  those  who  have 
never  taken  it  to  excess  or  used  it  habitually  Mitchell  gives  it  in  small 
daily  doses.  An  ounce  of  whisky  in  milk  or  a  glass  of  red  wine  or 
champagne  he  regards  as  a  useful  adjuvant,  as  it  increases  the  desire  to 
take  food  at  meals.  In  some  even  the  small  amount  contained  in 
malt  extract  may  cause  excitement,  and  for  these  cases  the  thicker 
malt  extracts  or  the  Japanese  extract,  which  is  made  from  barley 
and  rice,  are  prescribed. 

Iron  is  given  in  large  doses  as  soon  as  the  patient  begins  to  take 
solid  food,  and  sometimes  before.  The  form  is  not  of  as  much  impor- 
tance as  the  dosage.  The  carbonate  and  the  lactate  are  the  forms 
prescribed  by  Mitchell.  If  the  patients  claim  that  they  can  not  take 
iron,  five  grains  of  the  pyrophosphate  are  added  to  each  ounce  of 
malt,  and  it  is  given  without,  their  knowledge.  It  is  generally  well 
borne,  and  after  a  month's  time  it  may  usually  be  given  with  good 
results  in  the  ordinary  forms.  The  peptonates  of  iron  and  manganese 
may  also  be  administered  either  with  or  without  malt.  No  other 
drugs  are  given  except  as  needed  to  regulate  the  bowels — cascara, 
aloes,  etc.  When  the  patient  begins  to  sit  up,  strychnin  in  full  doses 
with  iron  and  arsenic  is  given, 

SCHEDULE  FOR  A  COMPLETE  REST-CURE. 

Until  otherwise  ordered,  absolute  rest  in  bed.  No  visitors,  no  reading,  and  no 
conversation  with  nurse  on  the  subject  of  disease  or  treatment. 

First  Day.- — 1  quart  of  milk  in  divided  doses  every  two  hours.  8  a.  m.  :  Cold 
bath  followed  by  a  brisk  rub.  If  patient  does  not  react  well,  a  warm  bath  may 
be  used  for  several  days  and  then  the  cold  bath  tried  again.  11  a.m.:  20 
minutes'  massage.  '2-3.30  P.  M. :  Room  darkened  for  a  nap.  4  P.  M. :  20  min- 
utes electricity.     9  P.  M. :     Brisk  rub  over  entire  body. 


THE  WEIR-MITCHELL  REST  CURE  563 

Second  Dai'. — t^ii'iip  'if*  first.  .Milk  U  quarts;  massage  and  electricity  increased 
to  40  minutes. 

Third  Day. — 2  quarts  of  milk  in  divided  doses  at  S-liour  intervals;  massage 
and  electricity  1  hour  each. 

Fourth  Day. — Same  with  addition  of  white  of  a  raw  egg  with  each  glass  of 
milk;  cup  of  cocoa  on  awakening. 

Fifth  Day. — Same  wath  addition  of  raw-beef  soup  or  broth,  1  pint  in  two 
portions;  a  slice  of  toast. 

Xinth  Day. — Same  with  soft-boiled  eggs  and  toast  for  breakfast. 

Tenth  Day. — Same  with  a  chop,  potato  and  junket  for  dinner — about  1.30  P.M. 

Twelfth  Day. — Cocoa  on  awakening.  7.30  a.m.:  Bath  and  brisk  rub.  8.30 
A.  ^^. :  Breakfast,  including  cereal,  chop  or  eggs,  bread  and  butter,  and  two 
glasses  of  milk  with  the  Avhites  of  two  eggs.  10-11  a.m.:  Massage.  11.30 
A.  M. :  i  Pint  milk,  whites  of  one  or  two  eggs.  2  p.  m.  :  Full  dinner,  including 
two  glasses  of  milk  and  whites  of  two  eggs  3.34-4  p.m.:  Electricity.  5.00 
P.M.:  Glass  of  milk  with  whites  of  two  eggs.  7.30  p.m.:  Supper  including 
milk  and  eggs.     9.30  p.  m.  :      Brisk  rub  and  a  glass  of  milk. 

Schedule  as  above  until  desired  effect  is  obtained.  This  to  be  modified  to 
suit  the  individual  case.  On  twelfth  day  it  is  well  to  give  two  oimces  of  malt 
extract  with  a  teaspoonful  of  solution  of  peptonate  of  iron  and  manganese. 
Hydrochloric  acid,  pepsin,  and  nux  vomica  are  useful  if  there  is  discomfort  after 
eating.     Bowels  to  be  kept  open.     Use  butter  in  as  large  quantities  as  possible. 

The  following  is  a  sample  schedule  ^  in  a  marked  case  in  a  patient 
of  thirty-three : 

"Patient  remained  in  bed  in  entire  repose.  She  was  fed.  and  rose 
only  for  the  purpose  of  relieving  the  bladder  and  rectum. 

' '  Oct.  10th :  Took  one  quart  of  milk  in  divided  doses  every  two 
hours. 

"11th:  A  cup  of  coffee  on  rising  and  two  quarts  of  milk  in  divided 
portions  every  two  hours.  A  pill  of  aloes  every  night,  which  an- 
swered for  a  few  days. 

"12th-15th:  Same  diet.  The  dyspepsia  by  this  time  was  relieved, 
and  she  slept  without  the  habitual  dose  of  chloral.  The  pint  of  raw 
soup  was  added,  in  three  portions,  on  the  16th. 

"17th  and  18th:  Same  diet. 

"19th:  She  took,  on  awaking  at  7,  coffee;  at  7.30  half-pint  of  milk; 
and  the  same  at  10  a.  m.,  12  m.,  2,  4,  6,  8,  and  10  p.  m.  The  soup  at 
11  A.  M.,  and  at  5  and  9  p.  m. 

"23d:  She  took  for  breakfast  an  egg  and  bread  and  butter;  and 
two  days  later  (25th)  dinner  was  added,  and  also  iron. 

"On  the  28th  this  was  the  schedule:  On  waking,  coffee  at  7.  At 
8,  iron  and  malt.  Breakfast,  a  chop  and  bread  and  butter;  of  milk, 
a  tumbler  and  a  half.  At  11,  soup.  At  2,  iron  and  malt.  Dinner 
closing  with  milk,  one  or  two  tumblers.  The  dinner  consisted  of  any- 
thing she  liked,  and  with  it  she  took  six  ounces  of  Burgundy  or  dry 
champagne.  At  4  soup.  At  7,  malt,  iron,  bread  and  butter,  and 
usually  some  fruit,  and  commonly  two  glasses  of  milk.  At  9,  soup ; 
at  10,  an  aloe  pill.  At  12  m,,  massage  occupied  an  hour ;  at  4.30 
p.  M.,  electricity  was  used  for  an  hour. 

"This  diet-list,  reached  in  a  few.  days  by  a  woman  who  had  been 

1  Fat  and  Blood,  p.   146. 


564  DIET  IX  DISEASE 

unable  to  digest  the  lightest  meal  with  comfort,  seemed  certainly 
remarkable.  She  began  to  gain  at  the  end  of  the  second  week;  the 
effect  was  noticed  in  her  face,  and  during  her  two  months  in  bed 
she  went  from  96  pounds  to  136,  and  the  gain  in  color  was  not  less 
marked.  At  the  sixth  week  the  soup  was  dropped,  wine  abandoned, 
the  iron  lessened  one-half,  the  massage  and  electricity  used  on  alter- 
nate days,  and  the  limbs  exercised  as  I  have  described.  The  usual 
precautions  as  to  rising  and  exercise  were  carefully  attended  to,  and 
at  the  end  of  the  ninth  week  of  treatment  my  patient  took  a  drive. 
At  this  time  all  mechanical  treatment  ceased,  the  milk  was  reduced 
to  a  quart,  the  iron  to  five  grains  three  times  a  day,  and  the  malt 
continued.  At  the  end  of  six  weeks  I  began  to  employ  strychnin  in 
doses  of  one-thirtieth  of  a  grain  thrice  a  day  at  meals,  and  this  was 
kept  up  for  several  months,  together  with  the  iron  and  malt.  The 
cure  was  complete  and  permanent." 

The  patient  is  allowed  to  undertake  movements  for  herself  very 
gradually,  being  allowed  to  move  about  in  the  bed  by  herself  and 
then  sit  up,  and  later  on  to  sit  out-doors,  and  then  to  walk  a  few 
steps,  to  take  a  drive,  etc.  If  this  is  not  done  gradually,  the  moving 
about  may  be  attended  by  dizziness,  vertigo,  or  unpleasant  exhaustion, 
which  may  be  avoided  entirely  by  gradually  increasing  the  patient's 
efforts  for  herself. 

Asthenopia  is  a  most  troublesome  symptom,  and  patients  who  do 
not  exhibit  it  generally  make  good  recoveries.  "Where  it  exists,  an 
ophthalmologist  should  be  consulted.  The  eye  trouble  may  persist 
long  after  all  other  symptoms  have  disappeared. 

The  following  schedule,^  abridged  from  Mitchell,  is  instructive  as 
showing  the  method  of  treating  a  man  who  continued  at  his  business 
while  undergoing  the  treatment.  The  patient  was  fifty-three  years 
old,  and  had  broken  down  after  thirty  3^ears  of  constant  application 
to  business.  He  had  a  cough,  was  greatly  emaciated,  and  exhibited 
numerous  nervous  symptoms. 

"6  A.M.:  A  tumbler  of  strong  beef -tea  made  from  the  Australian 
extract. 

"8  A.  M. :  Half  a  tumbler  of  iron  water  and  breakfast,  consisting  of 
fruit,  steak,  potatoes,  coffee,  and  a  goblet  of  milk. 

"8.30  A.M.:  A  goblet  of  milk  mixed  with  a  dessertspoonful  of 
Loefiand's  extract  of  malt,  with  six  grains  of  citrate  of  iron  and 
quinin. 

"10  A.  M.:  Electricity. 

"12  M.:  Dressed  with  as  little  personal  effort  as  possible;  a  second 
goblet  of  iron  and  malt  was  given  him,  and  a  carriage  took  him  to  his  -' 
office,  where  he  remained  two  hours,  a  carriage  bringing  him  back. 
Walking  was   forbidden.     He   was  then   given   dinner,   preceded   by 
half  a  tumbler  of  iron  water.     After  dinner,  which  included  a  goblet 

1  Fat  and  Blood,  p.   172. 


DIET  FOR  THE  IXSANE  565 

of  milk,  the  third  goblet  of  milk  and  malt  was  swallowed.  Then  a 
short  drive  might  be  taken.  By  4  o'clock  the  patient  must  be  un- 
dressed and  in  bed. 

**6  p.  M.:  The  third  dose  of  iron  water  and  a  light  supper  of  fruit, 
bread  and  butter,  and  cream,  followed  by  a  fourth  goblet  of  milk 
and  malt.  Two  quarts  of  milk  were  given  in  addition  to  the  other 
food. 

"9  p.  M. :  Massag-e  for  one  hour,  followed  by  beef -soup,  four  ounces. 

"From  125  pounds  he  went  up  in  six  weeks  to  133  pounds,  and 
reached  140  a  month  and  a  half  later,  and  has  continued  to  gain.  A 
year  later  he  was  well  and  strong,  and  had  ceased  to  be  what  he  had 
been  for  years— a  delicate  man. ' ' 

DIET  FOR  THE  INSANE 

Feeding  constitutes  a  very  important  part  of  the  treatment  of 
the  insane.  All  insane  patients  who  are  helow  the  standard  of 
nutrition  should  he  built  up,  and  an  earnest  effort  made  to  increase 
the  weight  of  the  patient.  One  of  the  English  alienists  was  wont  to 
talk  of  the  "gospel  of  fatness."  This  is  best  accomplished  hy  a 
sj^stem  of  feeding  somewhat  similar  to  that  outlined  in  the  rest  treat- 
ment, the  rest  being  prescribed  or  omitted  as  the  ease  demands.  It 
should  always  be  remembered  that  an  insane  person  may  contract 
other  diseases  besides  his  mental  disorder,  and  these  should  be  care- 
fully sought  for  and  properly  treated ;  this  is  true  especially  of 
stomach  and  intestinal  disorders,  which  may  give  rise  to  delusions 
regarding  the  taking  of  food. 

When  the  patient  refuses  food,  the  question  as  to  the  advisability 
of  feeding  him  by  force  arises;  opinions  are  divided  on  this  point. 
Everything  considered,  it  is  well  to  begin  the  forced  feeding  early, 
before  the  patient  has  time  to  suffer  from  his  fasting.  It  should  be 
accomplished  by  means  of  the  stomach-tube  or  the  nasal  tube,  and 
about  a  liter  (1  quart)  of  food  should  be  introduced.  The  food  may 
be  given  thus  twice  daily,  and  in  the  case  of  weak  patients  three  or 
four  times  a  day.  Milk,  milk  and  eggs,  and  broths  may  be  used  for 
this  purpose.  A  sufficient  number  of  attendants  should  be  at  hand 
to  control  the  patient  if  he  becomes  unruly  and  resists  feeding. 
After  a  patient  has  been  fed  with  the  tube  several  times  he  will  often 
prefer  to  take  his  nourishment  in  the  usual  manner. 

Whether  the  esophageal  or  the  nasal  tube  is  to  be  used  will  -depend 
on  the  preference  of  the  physician.  Each  has  its  advantages.  The 
nasal  tube  is  generally  preferred,  since  it  is  easier  to  introduce,  can 
not  be  bitten  by  the  patient,  and  does  not  cause  the  patient  to  struggle 
as  much  as  the  stomach-tube ;  it  may,  however,  be  passed  into  the 
larynx,  and  in  this  way  liquid  might  be  introduced  into  the  trachea. 
This  danger  is  more  fancied  than  real,  and  can  be  avoided  if  the 
patient  is  allowed  to  breathe  before  the  fluid  is  poured  into  the  tube. 


566  DIET  IN  DIHEAf^E 

While  he  is  breathing  the  tube  should  be  pinched,  and  if  it  is  in  the 
larynx,  this  fact  will  be  noticed  at  once.  Ordinarily,  but  not  always, 
coughing  ensues ;  it  does  not  follow  when  the  larynx  is  anesthetic,  as 
it  occasionally  is  in  the  insane  or  hysteric.  The  stomach-tube  does 
not  allow  the  food  to  be  regurgitated  so  easily  as  the  nasal  tube,  but 
for  this  method  of  feeding  a  mouth-gag  is  required  that  may  injure 
the  mouth  or  teeth,  or  it  may  slip,  permitting  the  patient  to  bite  the 
tube.  If  the  patient  has  acquired  the  knack  of  regurgitating  the 
food,  this  may  be  prevented  by  tickling  the  ribs  while  the  fluid  is 
being  introduced.  This  prevents  the  fixing  of  the  diaphragm,  and  is 
successful  in  most  cases. 

Tact  and  experience  in  handling  the  insane  are  of  the  greatest 
value.  Some  nurses  or  attendants  have  little  difficulty  in  getting 
patients  to  eat,  whereas  others  seem  never  to  learn  how  to  manage 
them.  It  must  be  remembered  that  an  insane  patient  may  not  eat 
for  reasons  that  are  often  easily  overcome.  He  may  prefer  to  take  his 
food  alone,  because  he  does  not  think  himself  worthy  of  eating  at 
the  same  table  or  with  other  people.  He  may  fear  that  his  food 
has  been  poisoned,  and  he  should  be  convinced  of  the  fallacy  of  this 
by  the  nurse  who  should  eat  a  portion  before  him,  or  allow  him 
see  the  food  prepared,  or  he  may  be  given  food  that  can  not  easily  be 
poisoned,  such  as  eggs,  whole  vegetables,  and  fruit.  When  the 
patient's  confidence  is  gained,  the  battle  is  generally  won.  In  some 
cases  the  delusion  persists  for  a  long  time  and  can  not  be  dispelled. 

Food  should  always  be  served  daintily.  An  insane  person  who 
may  be  very  much  unbalanced  may  still  notice  the  slightest  variations 
in  the  way  of  serving  food.  Attendants  are  apt  to  be  negligent  in 
this  respect.  For  all  patients  who  have  a  suicidal  tendency  the  food 
should  be  served  on  dishes  that  can  not  be  broken.  No  knives  should 
be  allowed,  and  the  food  should  be  so  served  as  to  require  no  cutting. 
An  attendant  should  watch  those  who  are  apt  to  bolt  their  food,  and 
see  that  it  is  cut  fine  before  serving  it.  Cases  of  sudden  death  have 
followed  the  drawing  of  a  piece  of  meat  into  the  larynx  while  eating 
too  rapidly. 

Children  of  very  nervous  parents  and  those  whose  constitutions 
are  of  the  nervous  type  require  careful  dietetic  supervision,  and  the 
child  should  be  trained  to  like  the  plain  and  wholesome  varieties  of 
food,  and  never  be  given  the  rich,  highly  seasoned  dishes  that  so  often 
disturb  the  digestion  of  nervous  children.  Milk  should  form  the  basis 
of  the  diet,  and  eggs  and  meat  should  be  given  in  moderate  quanti- 
ties along  with  cereals  and  the  wholesome  vegetables.  As  a  rule, 
infants  should  be  kept  on  a  milk  diet  for  a  longer  period  than  other 
children,  and  the  change  to  a  general  diet  should  be  made  with 
caution.  Tea  and  coffee,  as  well  as  alcohol,  should  always  be  for- 
bidden. Every  effort  should  be  made  to  nourish  the  child,  and  to 
have  him  lead  a  wholesome,  quiet,  out-of-door  life. 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR  567 

DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 

DIABETES 

Diabetes  is  a  disease  of  the  greatest  interest  to  the  student  of 
dietetics,  for  it  is  alone  by  the  regulation  of  the  diet  that  the  diabetic 's 
life  is  made  comfortable  and  his  days  prolonged.  The  disease  was 
knoAvn  to  the  ancients,  but  its  management  was  not  understood.  The 
sweet  taste  of  the  urine  was  known,  too,  but  Thomas  Willis  (1674) 
is  generally  credited  with  being  the  first  to  note  this  fact,  while  Rollo 
(1797)  Avas  the  first  to  use  dietetic  restrictions  in  the  treatment  of  the 
disease,  and  since  his  time  the  literature  is  so  extensive  that  mention 
cannot  be  made  even  of  the  most  important  contributions.  Among 
the  names  of  the  men  who  have  added  to  our  knowledge  of  diabetes 
are  Claude  Bernard,  Bouchardat,  Dujardin-Beaumetz,  Germain  See, 
Frerichs,  Ebstein,  Seegen,  von  Noorden,  Senator,  Kiilz,  Pavy,  Min- 
kowski, Lepine,  Naunyn,  Opie,  von  Mering,  Allen  and  Joslin. 

Diabetes  is  a  disease  in  which  the  capacity  for  utilizing  sugar  is 
more  or  less  depressed  and  the  unutilized  sugar  is  excreted  in  the 
urine.  There  is  normally  a  very  small  amount  of  sugar  which  may 
be  detected  by  refined  tests,  and  this  is  spoken  of  as  physiological 
glycosuria.  Temporary  glycosuria  may  be  induced  by  drugs,  injury 
or  excitement.  There  is  another  form  so-called  alimentary  glyco- 
suria due  to  the  ingestion  of  more  sugar  than  can  be  utilized.  The 
limits  of  this  sugar  tolerance  in  normal  persons  is  found  to  increase 
with  the  increased  ingestion,  while  in  diabetes  the  reverse  is  true,  i.  e., 
the  more  sugar  given  the  less  is  utilized.  In  the  diabetic  sugar  acts 
•as  a  diuretic  while  in  the  normal  person  it  does  not  unless  the  limit 
of  tolerance  is  overstepped.     (See  Glucose  Tolerance.) 

Addis  (Journal  American  Medical  Association,  July  14,  1917), 
has  recently  devised  a  simple  method  for  the  early  diagnosis  of  dia- 
betes. By  subjecting  the  tissues  to  a  successively  increased  amount  of 
work  in  assimilating  glucose,  a  defect  in  function  becomes  more  and 
more  apparent,  the  greater  the  strain  to  which  they  are  subjected,  and 
we  therefore  expect  to  find  evidences  of  an  increasing  failure  of 
function  in  the  presence  of  larger  and  larger  quantities  of  glucose  in 
the  urine.  According  to  his  test,  the  increasing  amounts  of  work 
are  given  in  the  form  of  25,  50  and  100  gms.  of  glucose  taken  on 
successive  days.  •  It  is  only  then  in  cases  in  which  the  glycosuria  is 
produced  by  failure  to  utilize  glucose  that  a  corresponding  rise  of 
sugar  is  manifested.  Addis  gives  instructions  for  out-patients  as 
follows. 

General. — The  test  consists  in  the  study  of  the  urine  after  giving 
a  measured  amount  of  a  special  sort  of  sugar.  On  the  first  day,  a 
measured  amount  of  water  but  no  sugar  is  taken  in  order  to  find  out 
the  amount  and  character  of  the  urine  when  no  sugar  is  taken.     On 


568  DIET  IN  DISEASE 

the  second  day,  25  gm.  of  sugar  are  taken  with  water  at  the  begin- 
ning of  the  day,  on  the  third  50  gm.,  and  on  the  fourth  day,  100  gm. 
Each  day  the  test  extends  over  a  period  of  four  hours,  beginning  from 
the  moment  j^ou  rise  from  bed.  The  urine  must  be  passed  at  the 
end  of  the  second  and  at  the  end  of  the  fourth  hours.  It  is  very  im- 
portant to  note  the  exact  time  of  taking  the  water,  or  the  water  with 
the  sugar  dissolved  in  it,  and  the  urine  must  be  passed  exactly  two 
hours  later. 

All  the  urine  passed  at  the  end  of  the  second  hour  goes  into  one 
bottle,  and  all  the  urine  passed  at  the  end  of  the  fourth  hour  into 
another  bottle.  This  is  an  important  point.  We  cannot  get  reliable 
information  unless  the  total  amount  of  urine  is  brought.  Write  your 
name  on  the  bottle  and  put  "No.  1"  on  the  first  bottle,  and  "No.  2" 
on  the  second,  and  bring  or  send  them  to  the  hospital.  At  the  end  of 
the  fourth  hour  on  each  day,  the  test  is  ended  for  that  day,  and  you 
can  eat  or  drink  as  you  please. 

Instructions  for  the  First  Day. — A.  In  the  morning  when  you  rise 
from  bed : 

1.  Pass  all  urine. 

2.  Immediately  afterward  drink  1  pint  of  water;  if  you  have  not 
a  pint  measure,  use  an  empty  pint  milk  bottle  as  a  measure. 

3.  Make  a  note  of  the  time. 

4.  Take  no  breakfast. 

B.  Exactly  two  hours  later : 

1.  Pass  all  urine  and  collect  all  of  it  in  a  corked  bottle  to  which  you 
will  attach  the  label  marked  "First  Day — Specimen  1." 

2.  Immediately  afterward,  drink  a  pint  of  water. 

3.  Make  a  note  of  the  time. 

4.  Take  two  boiled  eggs  or  poached  eggs  without  salt,  but  take  no 
other  food. 

C.  Exactly  two  hours  later: 

1.  Pass  all  urine  and  collect  all  of  it  in  a  corked  bottle  to  which 
you  will  attach  the  label  marked  "First  Day — Specimen  2." 

This  is  the  end  of  the  test  for  the  first  da3\ 

Write  your  name,  address,  and  clinic  number  (the  number  on  the 
card  you  received  at  the  historj^  room)  on  the  labels  and  bring  them 
any  time  before  3  p.  m.  on  the  same  day. 

Similar  detailed  instructions  are  given  for  the  other  days,  with 
the  exception  that  the  patient  is  told  to  take  25  gm.  of  glucose  on  the 
second  day,  50  gm.  on  the  third  day,  and  100  gm.  on  the  fourth  day, 
dissolved  in  the  first  pint  of  water. 

The  characteristics  common  in  all  cases  of  diabetes  is  the  con- 
siderable relative  increase  in  glucose  secretion  with  increase  in  quanti- 
ties taken.  According  to  Addis,  it  is  on  this  evidence  of  a  relation 
between  the  extent  of  the  failure  to  assimilate  glucose  to  the  degree 


DISEASES  ly  WHICH  DIET  IS  A  PRIMARY  FACTOR  569 

of  strain  imposed  on  the  assimilative  functions  that  the  diagnosis  is 
based. 

Joslin  regards  every  patient  with  sugar  in  his  urine  as  a  diabetic 
and  treats  him  as  such,  and  he  believes  that  this  has  a  great  effect 
on  prolonging  and  saving  life^  as  the  earlier  the  treatment  is  begun 
the  better  the  results  and  many  a  diabetic  is  allowed  to  become 
very  ill  through  carelessness  or  failure  to  recognize  the  disease. 

There  seems  to  be  a  certain  amount  of  hereditary  influence  and 
persons  from  families  with  a  diabetic  history  will  doub'tless  do  well  to 
follow  some  sort  of  a  prophylactic  diet.  The  disease  is  also  very 
common  among  the  Jews. 

The  etiology  of  the  disease  is  not  clear,  but  Allen  has  been  able 
to  produce  the  disease  experimentally  in  dogs  by  operations  on  the 
pancreas  and  there  are  lesions  in  the  islands  of  Langerhans.  The 
pancreas  secretion  which  regulates  the  intermediary  carbohydrate 
metabolism  is  deficient  and  the  carbohydrate  is  not  utilized  as  a  con- 
sequence. Sooner  or  later  there  is  also  a  limit  to  the  protein  metab- 
olism and  then  to  the  fats.  "We  need  not  consider  here  the  relation  of 
the  disease  to  the  ductless  glands  or  the  nervous  system.  There  is  a 
rare  form  of  renal  glycosuria  in  which,  due  to  kidney  lesions,  sugar 
is  allowed  to  pass.  As  exciting  factors,  obesity,  especially  when 
combined  with  a  sedentary  life  and  dietary  excesses,  are  the  most 
important. 

The  strict  treatment  of  diabetes  is  most  important  and  cannot  be 
too  strongly  insisted  upon,  and  the  cooperation  of  the  patient  must 
be  secured  by  explaining  the  importance  of  it.  The  strict  dietetic 
treatment  tends  to  lengthen  life,  and  to  avoid  the  numerous  compli- 
cations which  are  sure  to  ensue  if  he  neglects  himself.  Tuberculosis, 
septic  infections,  inanition  and  acidosis  being  the  most  common. 

In  former  days  entirely  too  much  attention  was  paid  to  the  carbo- 
hydrate content  of  the  food  and  not  enough  to  the  fat  and  protein. 
The  importance  of  the  latter  is  being  rapidly  appreciated  and  a  full 
discussion  of  the  role  of  fat  in  diabetes  will  be  found  in  the  article 
of  Allen  in  the  (American  Journal  of  the  Medical  Sciences)  March, 
No.  3,  Vol.  cliii,  p.  313,  together  with  a  considerable  bibliography. 

The  only  satisfactory  way  of  following  a  case  is  by  frequent  exami- 
nations of  the  urine.  The  elaborate  urinary  analyses  made  in  re- 
search hospitals  while  desirable  for  the  more  complete  understanding 
of  the  case  are  not  absolutely  necessary,  and  very  satisfactory  work 
may  be  done  with  limited  laboratory  facilities.  For  the  mild  cases 
the  patient  may  be  taught  to  test  his  own  urine  or  some  member  of  his 
family  may  do  it  for  him.  Benedict's  test  will  be  found  simple  and 
satisfactory.  In  the  more  severe  cases  the  progress  of  the  disease 
must  be  followed  by  making  routine  examinations  of  the  twenty- 
four  hour  specimens,  not  only  for  the  presence  of  sugar,  but  the 


570  DIET  IN  DISEASE 

amount  passed.     This  frequently  coincides  roughly  with  the  specific 
gravity  and  von  Noorden  gives  the  following  table : 

Volume  of  urine,  specific  gravity  and  percentage  of  urine  com- 
pared. 

Amount  of  Urine.                                            Specific  Sugar 

C.c.                                                        Gravity.  Percentage. 

1500-2500  1025-1030  2-3 

2500-4000  1030-1036  3-5 

4000-6000  1032-1040  4-7 

6000-10,000  1036-1046  6-9 

This  should  not  be  depended  upon,  but  furnishes  a  rough  guide. 
It  is  also  desirable  to  know  whether  diacetic  acid  is  present  and  the 
ferric  chlorid  test  will  be  found  of  value  for  the  qualitative  test. 
There  are  a  number  of  tests  for  determining  the  quantity  not  only 
of  the  diacetic  acid,  but  of  the  oxybutyric  acid  and  the  acetone  as 
well.  Albumin  and  casts  should  also  be  watched  for  and  the  esti- 
mation of  the  chlorids  maj^  throw  light  on  some  cases  with  varying 
weights.  The  reader  is  referred  to  such  works  as  Joslin's  regarding 
the  technic  and  significance  of  blood  tests.  The  best  method  for 
studying  acidosis  is  by  measuring  the  carbon  dioxid  tension  of  the 
alveolar  air  and  some  of  the  simpler  methods,  such  as  Friedericia's  or 
Marriott's  is  generally  chosen.  The  fact  remains  that  most  diabetics 
have  to  be  managed  without  these  more  complicated  and  time  con- 
suming diagnostic  methods  and  very  good  work  can  be  accomplished 
without  them. 

The  Fatal  Ratio. — Mandel  and  Lusk  have  suggested  a  method  for 
prognosis  in  diabetes.  The  patient  is  placed  on  a  meat  fat  diet, 
consisting  of  meat,  rich  cream,  butter  and  eggs.  The  urine  is  col- 
lected on  the  second  day  so  that  an  early  morning  hour  before  break- 
fast terminates  the  period  for  one  day.  If  the  amount  of  dextrose 
and  nitrogen  is  3.65  to  1  it  signifies  a  complete  intolerance  for  carbo- 
hydrates and  probably,  though  not  necessarily  a  rapidly  fatal  out- 
come. If  the  ratio  is  lower  it  means  that  some  carbohydrates  may 
be  utilized.  This  test  is  not  advised  under  ordinary  conditions,  as 
it  is  not  desirable  to  place  a  severe  diabetic  on  such  a  diet. 

It  should  be  remembered  that  under  forty  diabetes  is  almost  al- 
ways a  very  formidable  disease  and  the  prognosis  none  too  good,  but 
wonderful  results  are  obtained  if  the  patient  is  willing  to  cooperate 
fully.  After  forty  the  outlook  is  better,  but  the  diet  should  receive 
great  attention  to  prevent  complications.  Reisman  has  called  atten- 
tion to  a  mild  form  of  diabetes  in  children  with  a  good  prognosis  and 
he  believes  that  such  cases  are  more  common  than  ordinarily  thought. 

The  prophylactic  diet  is  to  be  recommended  in  all  people  from 
diabetic  families,  in  all  who  have  had  glycosuria  at  any  time,  and  in 
the  obese.  The  carbohydrate  should  be  restricted  and  likewise  the 
fats,  and  the  urine  examined  at  stated  intervals.     The  general  hy- 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR  571 

giene  should  receive  attention  and  also  the  mental  attitude  of  the 
patient.  Plenty  of  rest,  exercise,  especially  in  the  open  air  and  a 
suitable  occupation  are  all  as  important  as  the  diet. 

The  habits  and  mode  of  life  of  all  diabetics  is  a  matter  of  much 
importance  and  the  whole  question  of  the  manner  of  living  should 
be  gone  into  and  arranged  according  to  the  circumstances  of  the 
patient. 

The  classification  of  diabetes  vv^ith  regard  to  the  diet  is  best  made 
in  mild  eases  in  which  the  urine  is  free  from  sugar  notwithstanding 
the  administration  of  from  50  to  150  grams  of  starch,  the  moderately 
severe  cases  in  which  sugar  is  found  unless  nearly  all  the  carbohy- 
drate is  withdrawn  from  the  diet  and  the  severe  cases  in  which  there 
is  glycosuria,  even  though  the  patient  is  on  a  carbohydrate  free  diet. 
On  such  a  diet  the  patient  will  be  getting  about  10  grams  of  carbo- 
hydrate if  he  is  using  the  5  per  cent,  vegetables. 

The  milder  forms  should  be  furnished  with  diet  lists  like  the  fol- 
lowing and  the  food  need  not  be  weighed  but  the  restrictions  made 
along  the  qualitative  lines  rather  than  quantities.  The  urine  should 
be  regularly  examined  and  should  be  free  from  diacetic  acid  and 
sugar.  The  patient  may  be  taught  to  make  the  tests  or  some  one  in 
his  family  may  make  them  for  him.  The  diet  should,  be  supervised  by 
having  the  patient  list  exactly  what  he  eats,  either  one  day  a  week 
or,  in  certain  cases,  two  days  a  week.  There  is  a  tendency  to  become 
lax  and  take  articles  of  food  which  are  forbidden  and  many  times 
this  is  done  through  ignorance. 

Starch  Free  Diet — {Mosenthal) . 
May  Eat: 

Soups — Clear  meat  broths. 

Meats — All  kinds  of  meat,  fresh,  smoked,  or  cured;  except  liver;  all  meats 
must  be  prepared  without  flour  or  breadcrumbs. 

Fish — All  kinds  of  fish,  but  no  clams,  oysters  or  scallops. 

Eggs — Eggs  in  any  form,  prepared  without  milk,  flour  or  sweetening  (sugar, 
jam,  etc.) . 

Butter — Butter,  oil,  and  lard. 

Cheese — All  kinds  of  cheese. 

Vegetables — Greens,  spinach,  string-beans,  Brussels  sprouts,  asparagus,  kohl- 
rabi, rhubarb,  egg-plant,  water  cress,  lettuce,  endive,  cucumbers,  celery, 
cabbage,  mushrooms,  tomatoes,  sour  pickles,  sauerkraut,  sorrel,  Swiss 
chard,  cauliflower. 

Gluten  Products — "Akoll"  biscuits. 

Desserts — Gelatin  jellies  (use  sour  white  wine,  brandy  or  coffee  for  flavor- 
ing). 

Beverages — Tea  and  coffee,  sweetened  with  saccharine  (without  sugar  or 
milk)  ;  claret,  burgundy,  sour  white  wine,  and  whisky  in  moderate 
amounts.     Vichy  and  water. 

Condiments — Pepper,  salt,  mustard,  oil,  vinegar. 
Must  Avoid  Eating: 

Sugar  in  any  form.  Bread,  biscuits,  and  cakes  of  all  kinds.  Toast,  crackers, 
rice,  oatmeal  (and  all  cereals)  ;  sago,  tapioca,  macaroni,  vermicelli,  pota- 
toes, carrots,  parsnips,  'beets,  corn,  beans,  peas.  All  fruits,  fresh,  pre- 
served and  dried.  Jams  and  jellies.  Pastry,  puddings,  and  ice  cream. 
Sauces  and  gravies  thickened  with  flour. 


572  DIET  ly  DISEASE 

Must  Avoid  Drinking: 

Milks,  ales,  porter,  stout,  beer,  cider,  all  sweet  wines,  port  wine,  liqueurs, 
sparkling  wines,  syrups. 

General  Diabetic  Diet  List. 
May  Take  Freely: 

Soups:  All  meat  soups  and  broths.  May  add  vegetables  allowed,  egg  or 
cheese. 

Meats:  All  fresh,  smoked  and  cured  meats  (except  liver),  poultry  and 
game,  without  sauces  or  gravies  containing  flour,  pate  de  foie  gras. 

Fish:  All  kinds,  except  oysters,  clams  and  scallops,  cooked  without  bread 
crumbs  or  meal;  all  dried,  salted,  smoked  or  pickled  fish. 

Eggs:      Prepared  in  any  way  without  flour. 

Fats:      Butter,  lard,  suet,  olive  oil,  or  other  fats. 

Cheeses:     All  kinds,  especially  cream,  Swiss,  English,  and  pineapple  cheese. 
■     Vegetables    and    Salads:     Asparagus,    beet    greens,    Brussels    sprouts,    cab- 
bage, cauliflower,  celery,  chicory,  cresses,  cucumbers,   endive,   egg-plant, 
kohl-rabi,    leeks,    lettuce,    okra,    pumpkin,    radishes,    rhubarb,    salsify, 
sauerkraut,  spinacli,  string-beans,  tomatoes,  vegetable  marrow. 

Pickles:     Made  from  the  above  vegetables,  unsweetened;   ripe  olives. 

Fungi :      Mushrooms  and  truffles. 

Cream:      Not  over  3  ounces  a  day. 

Condiments :  Salt,  pepper,  cayenne,  paprika,  curry,  cinnamon,  cloves,  Eng- 
lish nuistard,  nutmeg,  caraway,  capers,  vinegar,  and  the  piquant  sauces 
in  small  quantities,  unless  specially  forbidden. 

Desserts :  Jellies  made  from  gelatin ;  custards  and  ice-cream  made  with 
eggs  and  cream;  all  sweetened  with  saccharin  and  flavored  with  vanilla, 
coffee,  or  brandy. 

Nuts :      Butternuts. 

Beverages :  Tea  or  coffee,  sweetened  with  saccharin,  and  with  the  portion 
of  cream  allowed. 

Whisky,  brandy,  rum,  and  other  distilled  liquors,  up  to  3  ounces  a  day, 
light  Rhine  wine  or  Moselle  wine,  claret  or  Burgundy,  up  to  16  ounces 
a  day    (one  pint) . 

Mineral  waters  of  all  kinds. 

Lemonade  in  small  quantity,  sweetened  with  saccharin. 
Articles  Prohibited,  Except  as  Prescribed  in  the  Accessory  Diet: 

Sugars  and  sweets  of  every  kind. 

Pastry,  puddings,  preserves,  cake  and  ice-cream. 

Bread  and  biscuits  of  all  kinds,  toast,  crackers  and  griddle  cakes. 

Cereals,  such  as  rice,  oatmeal,  sago,  hominy,  tapioca  and  barley. 

Macaroni,  potatoes,  carrots,  parsnips,  beans,  peas,  beets,  green  corn  and  tur- 
nips. 

Fruit  of  all  kinds,  fresh  or  dried. 

Soups,  sauces  or  gravies  thickened  with  flour  or  meal,  or  made  with  milk. 

Beer,  ale,  porter,  all  sweet  wines,  sherry  or  port  wine,  sparkling  wines, 
cider,  and  liqueurs. 

Milk,  chocolate  or  cocoa. 

All  sweet  drinks  and  soda  water. 

GENERAL  DIABETIC  DIET  LIST. 

Allowed  Freely.  Prohibited  except  as  ordered. 

1.  Meat  soups,  broths,  bouillon.  1.  Sugars  and  sweets  of  all  kinds. 

2.  All  fresh,  smoked  and  cured  meats,         2.  Pastry,  puddings,  cake,  preserves. 

but   without   gravies   made   with         3.  Bread,      biscuits,      toast,      cookies, 
flour.  crackers. 

3.  All  fresh,  dried,   salted  or   smoked         4.  Rice,  oatmeal,   sago,   hominy,   tapi- 

fish       cooked       without       bread  oca,  barley. 

crumbs  or  meal.  5.  Macaroni,    potatoes,    carrots,    par- 

4.  Eggs  in  any   form,  without  flour.  snips,    beans,    peas,    beets,    green 

5.  Butter,    lard,    olive    oil    and    other  corn,  turnips. 

fats.  6.  Fruit  of  all  kinds,  fresh  or  dried. 


« 


DISEASES  IX    WHICH  DIET  IS  A   rUIMARY  FACTOR  573 

6.  Asparagus,      cabbage,      caiilillower,         7.  Milk,  chocolate  or  cocoa. 

celery,    cress,    egg    plant,    cucum-  S.  .Soups,    sauces,    or    gravies,    thick- 

bers,      radishes,      lettuce,      okra,  ened  with  Hour  or  meal,  or  made 

pumpkin,     rhubarb,    spinach,    to-  with  milk. 

matoes,      string      beans,      sauer-  9.  Beer,     ale,      sherry,     cider,     sweet 

kraut,   mushrooms.  wines 

7.  Cream,  up  to  3  oz.  a  day.  10.  Sweetened      drinks,      soda      water, 

8.  Condiments   unless   forbidden.  etc. 

9.  Desserts    made    from    gelatin,    cus- 

tards and  ice  cream  made  with 
cream,  eggs,  and  saccharin, 
flavored  with  vanilla,  coff^  or 
brandy.  ^ 

10.  Tea  or  coffee,  with  saccharin;  dis- 
tilled liquors  3  oz.  a  day.  Min- 
eral waters  of  all  kinds.  Rhine 
wine  or  claret,  1  pint  a  day. 

If  the  patient  remains  free  from  sugar  on  such  a  diet  starchy- 
foods  may  be  gradually  added.  For  convenience  it  is  well  to  have 
at  hand  lists  of  food  showing  the  carbohydrate  equivalents.  Ab- 
stracts of  these  may  be  furnished  the  patient.  One  very  convenient 
list  .shows  the  equivalents  to  one  oiuice,  30  grams,  slices  of  bread. 
The  patient  may  be  allowed  one  or  more  slices  of  bread  or  he  may 
substitute  for  any  slice  one  of  the  equivalents.  The  urine  must  be 
watched  and  if  any  glycosuria  occurs  the  diet  must  at  once  cut  back. 
For  a  few  days  it  may  be  made  carbohydrate  free  and  then  increased 
up  to  about  70  per  cent,  of  the  amount  of  carbohydrate  at  which  the 
glycosuria  occurred.  From  time  to  time  the  tolerance  may  be  tested 
and  if  it  is  increasing  the  outlook  is  good,  whereas  if  it  is  decreasing 
the  dietary  restrictions  must  be  made  greater.  From  the  beginning 
of  the  treatment  it  is  well  to  have  the  patient  take  one  day  a  week 
on  a  carbohydrate  free  diet,  the  so-called  metabolic  Sunday  of  Von 
Noorden.  Where  the  tolerance  is  about  50  grams  of  starch  or  better, 
the  diet  for  that  day  may  be  merely  chosen  from  the  list  of  car- 
bohydrate foods  given  above,  but  if  the  tolerance  is  less  than  this,  the 
total  intake  of  food  must  be  restricted  and  a  diet  like  the  one  given 
below  containing  1000  calories  and  free  from  carbohydrate  as  sug- 
gested by  Mosenthal.  These  fast  days  are  of  great  value  in  keeping 
the  tolerance  up  and  preventing  acidosis.  If  the  patient  does  not 
become  free  from  sugar  readily  he  must  be  fasted  according  to  the 
method  suggested  by  Allen  and  which  has  revolutionized  the  treat- 
ment and  prognosis  of  the  disease. 

DIABETES  MELLITUS— THE  ACCESSORY  DIET  OF  FOODS  RICH  IN 
CARBOHYDRATES.      (MOSENTHAL.) 

If  the  patient 's  urine  continues  to  be  sugar-free  on  a  "  carbohydrate- 
free"  diet  of  sufficient  caloric  value,  carbohydrate-containing  foods 
may  be  added  and  the  carbohydrate  tolerance  of  the  patient  be  de- 
termined.    In  those  cases  able  to  utilize  a  considerable  amount  of 


574 


DIET  ly  DISEASE 


starch,  the  accessory  diet  may  be  varied  from  day  to  day,  and  use 
may  be  made  of  the  following  table,  which  gives  the  carbohydrate 
equivalent  of  one  slice  (1  ounce  or  30  grams)  of  white  bread,  con- 
taining approximately  15  grams  of  starch. 


Foods. 

Uncooked  Flours,  etc.  : 

Barley    

Buckwheat    

Cornmeal     

Farina    

Hominy    

Macaroni   

Noodles    

Oatmeal  

Rice    

Rye  flour  

Spaghetti ■.  .  . 

Vermicelli   

Wheat  flour 

Bread  and  Crackers: 

Bread     

Breakfast  biscuit   (Huntley  &  Palmer) 

Cornbread    

Roll    (Vienna)    

Uneeda   Biscuit    , 

Zwieback     

Cooked  Cereals: 

"Force"    

Farina    

Grapenuts   

Hominy    

Macaroni   

Oatmeal   

Rice    

Shredded  Wheat  Biscuit   

Cooked  Vegetables: 

Artichokes 

Beans  ( baked — canned )    

Beans,  lima 

Beets    

Carrots  

Okra  

Onions    , 

Parsnips  

Peas,  green 

Potato    ( baked )    

Potato   ( boiled ) 

Potato  ( mashed )    

Potato,  sweet  ( boiled )    

Squash    , 

Turnips    

Fruits : 

Apple      , 

Apricots     

Banana   ( without  skin )    

Cherries 

Currants      

Grapefruit     

Huckleberries      

Lemons  


Household 

Measure. 

1 

h.  tbsp. 

1 

1 

" 

1 

« 

1 

" 

1 

ii 

U 

a 

1 

<c 

1 

" 

1 

" 

u 

" 

u 

" 

1 

(£ 

1 

slice 

3 

1 

slice 

* 

3 

U 

5 

h.  tbsp. 

'M 

n 

H 

1 

2i 

i 

a 

1 

medium 

2 

h.  tbsp. 

H 

cc 

6 

" 

13 

IC 

4 

il 

3 

4 

slices 

3 

h.  tbsp. 

i  medium 

* 

medium 

U 

h.  tbsp 

i 

medium 

2 

h.  tbsp. 

3 

1 

medium 

2 

large 

i 

medium 

5 

h.  tbsp. 

i 

small 

3^ 

h.  tbsp 

2 

met 

lium 

Gm. 

21 
19 
20 
20 
18 
20 
20 
22 
18 
18 
20 
21 
20 

30 
18 
32 
25 

18 
20 

18 

125 

20 

90 

100 

130 

60 

22 

320 

75 

50 

200 

440 

200 

300 

120 

100 

60 

70 

80 

35 

100 

210 

120 

120 

75 

90 

120 

150 

90 

210 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 


575 


Foods.  Household 

Measure. 

Muskmelon    ^ 

Nectarine     1 

Olives,   green    20 

Orange *  large 

Peaches    1^'  medium 

Pear      1  small 

Pineapple     3  slices 

Plums     2  medium 

Raspberries     4i  h.  tbsp. 

Strawberries     8 

Watermelon    Large  slice 

Dried  Fruits: 

Apples      3  small 

Apricots     3  large 

Currants      IJ  tbsp. 

Dates      3 

Figs      ■ 1  large 

Prunes      2 

Raisins     10      " 

Milk  and  Cream: 

Buttermilk      li  tumbler 

Cream,   16  per  cent li         " 

Cream,  40  per  cent li         " 

Kumiss H          " 

Whole  milk    l| 

Xuts: 

Almonds      60 

Brazil     30 

Chestnuts    (roasted)     15 

Cocoanut      1  slice    (3x2    in. ) 

Filberts      100 

Peanuts     40 

Pecans      35 

Pistachio     190 

Walnuts  , 30 


Gm. 

300 
100 
180 
150 
150 
100 
150 
75 
120 
200 
300 

22 
24 
20 
19 
12 
24 
23 

300 
300 
300 
300 
300 

90 
180 

40 

50 
100 

80 
110 

95 
125 


The  Allen  Fasting  Treatment. — This  plan  of  treatment  is  based 
entirely  upon  the  knowledge  acquired  by  laboratory  investigation. 
Allen  produced  a  condition  in  animals  which  simulated  human  dia- 
betes by  partial  pancreatectomy  with  preservation  of  the  pancreatic 
duct,  so  as  to  avoid  atrophy  of  the  remainder  of  the  pancreas.  Ac- 
cording to  the  degree  of  pancreatic  destruction,  the  intensity  of  the 
disease  could  be  made  to  \ary  from  the  mildest  to  the  most  severe 
type.  The  dogs  in  which  glycosuria  was  produced  in  this  manner, 
were  observed  to  fail  progressively  and  to  ultimately  die  in  coma 
when  fed  liberally.  Those  that  were  starved  until  glj^eosuria  dis- 
appeared and  were  then  placed  upon  a  low  diet  were  seen  to  do  well, 
and  there  was  no  reappearance  of  glycosuria.  As  a  direct  outcome 
of  this  work  the  Allen  treatment  has  been  applied  to  human  beings. 

To  make  clear  the  basis  for  this  special  plan  of  treatment  it  may 
be  briefly  stated  that  the  best  established  and  most  generally  accepted 
theory  regarding  diabetes  is  that  this  affection  results  from  a  de- 
ficiency of  the  internal  secretion  of  the  pancreas.  In  the  early  cases 
there  is  a  weakness  of  the  pancreatic  function  which  may  be  broken 


576  DIET  IX  DISEASE 

down  by  overwoirk  or  strengthened  by  rest.  In  the  more  chronic  cases 
actual  organic  changes  in  the-  islands  of  Langerhans  are  found  micro- 
scopically. In  a  few  cases,  there  is  gross  destruction  of  pancreatic 
tissue  by  infection  or  otherwise,  and  in  these  cures  have  been  effected 
by  simple  drainage  of  the  gall-bladder, 

Allen's  Routine  for  Diabetes. — The  treatment  of  diabetes  should  be 
carried  out  in  a  hospital.  For  twenty-four  hours  after  admission 
the  patient  shoidd  be  kept  on  his  customary  diet  in  order  to  deter- 
mine the  severity  of  the  disease.  The  patient  is  then  starved,  being 
allowed  no  food  whatever  except  black  coffee,  tea  or  clear  broths.  A 
cup  of  black  coffee  or  clear  broth  is  given  every  few  hours,  and  whisky 
if  required. 

The  patient  need  not  remain  in  bed  during  the  fast  and  water  may 
be  given  freely.  It  is  not  necessary  to  give  alkalis  unless  acidosis  is 
present.  After  the  urine  has  been  sugar  free  from  twenty-four  to 
forty-eight  hours,  150  grams  of  vegetables  containing  5  per  cent, 
carbohydrates  are  added  to  the  diet.  These  vegetables  should  be 
boiled  in  three  changes  of  water  in  order  to  reduce  the  carbohydrate 
content.  Five  grams  of  carbohydrates  are  added  every  other  day, 
passing  successively  through  the  5,  10  and  15  per  cent,  vegetables 
until  glycosuria  appears.  It  is  just  as  important  to  detennine  the 
protein  and  fat  tolerance  as  it  is  to  estimate  that  of  carbohydrate ; 
for  it  has  been  observed  that  patients  who  are  constantl.v  sugar-free 
on  a  given  diet  will  show  glycosuria  if  an  additional  quantity  of  fat 
and  protein  are  added. 

The  Protein  Tolerance. — As  to  increasing  the  protein,  Joslin  gives 
the  following  rule :  M^hen  the  urine  has  been  sugar-free  for  two 
days,  add  20  grams  protein  (three  eggs)  and  thereafter  15  grams 
protein  daily  in  the  form  of  lean  meat,  fish  and  eggs  until  the  patient 
is  receiving  1  gram  protein  per  kilogram  body  weight,  or  if  the  car- 
bohydrate tolerance  is  zero,  only  %  gram  per  kilogram  body  weight. 
Later,  if  desired,  the  protein  may  be  raised  to  1.5  gram  per  kilogram 
body  weight. 

Fat  Tolerance. — While  testing  the  protein  tolerance,  a  small  quan- 
tity of  fat  is  included  in  the  eggs  and  meat  given.  Add  no  more  fat 
until  the  protein  reaches  1  gram  per  kilogram  (unless  the  protein 
tolerance  is  below  this  figure),  but  then  add  25  grams  fat  daily  until 
the  patient  ceases  to  lose  weight  or  receives  not  over  40  calories  per 
kilogram  body  weight.     (Joslin.) 

If  the  patient  is  one  in  whom  acidosis  has  been  an  essential  factor, 
or  if  the  patient  is  obese,  the  fat  should  be  increased  slowly,  5  to  10 
grams  a  day  is  all  that  can  be  added  without  producing  an  acidosis. 

The  danger  of  fat  in  the  diabetic  cannot  be  overestimated.  It  is 
the  chief  source  of  acidosis,  though  to  a  lesser  degree  the  amino-acids 
of  the  protein  molecule  with  even  number  of  carbon  atoms  contribute 
as  well.     Joslin  says  ' '  fat  at  one  time  may  save  the  life  of  the  diabetic. 


DISEASES  IN  MHICH  DIET  IS  A   PRIMARY  FACTOR  577 

but  at  another  period,  it  may  destroj'  it.  There  is  no  more  potent 
agreney  in  the  prevention  of  acidosis  than  the  withdrawal  of  fat  from 
the  diet. ' ' 

The  Recurrence  of  Sugar. — The  appearance  of  sugar  in  the  urine 
is  the  signal  for  instituting  fast  days  until  the  urine  is  sugar-free 
again.  The  previous  diet  of  the  patient  may  at  once  be  resumed 
except  for  the  elimination  of  half  of  the  carbohydrates  or  the  original 
course  of  treatment  may  again  be  followed,  passing  through  the  dif- 
ferent stages  at  a  more  rapid  rate.  The  original  fast  may  last  from 
two  to  eight  days,  but  usually  not  over  four  days.  There  are  no  con- 
traindications to  the  fast  except  perhaps  nausea,  vomiting  and  great 
prostration ;  if  these  symptoms  supervene  they  can  be  overcome  by 
feeding,  and  then  after  a  short  period  another  fast  can  be  undertaken, 
without  their  appearance.  Weekly  fast  daj's  following  this  plan  of 
treatment  should  be  recommended,  especially  in  the  severe  forms  of 
diabetes,  whereas  vegetable  days  will  usually  suffice  in  the  milder  forms. 

The  treatment  as  outlined  is  the  plan  used  in  handling  mild  or 
moderatelj'  severe  cases.  Joslin  modifies  this  plan  in  severe,  long 
standing,  complicated,  obese  and  acidosis  cases  as  follows:  Without 
otherwise  changing  their  habits  of  diet,  he  omits  fat,  and  after  two 
days  he  omits  protein,  then  the  carbohydrates  are  halved  daily  until 
the  patient  is  taking  10  grams  of  carbohydrates ;  the  fast  is  then 
undertaken  and  the  remainder  of  the  course  of  treatment  is  similar 
to  the  method  already  described.  This  plan  of  preparing  the  patient 
for  the  starvation  period  greatly  minimizes  the  possibility  of  the 
occurrence  of  acidosis,  and  in  the  cases  in  which  acidosis  already 
exists  the  source  of  acid  poisoning  is  removed.  In  the  acidosis  cases 
it  is  best  to  give  sodium  bicarbonate  for  a  few  days  during  the  fasting 
period. 

Joslin  warns  against  the  prolonged  use  of  alkalis,  for  in  many  cases 
an  acidosis  is  kept  up  by  such  a  procedure,  the  acidosis  promptly  dis- 
appearing upon  the  withdrawal  of  the  alkali. 

Inasmuch  as  the  diet  must  be  carefully  watched  even  when  the 
patient  is  no  longer  under  the  immediate  care  of  the  physician,  it  will 
be  well  to  interest  the  patient  in  his  condition,  especially  in  regard  to 
his  food.  He  is  urged  to  keep  a  record  of  the  quantity  and  character 
of  his  food,  and  to  keep  within  the  limits  of  his  tolerance.  The  food 
should  be  weighed,  and  for  this  purpose  the  food  scale  as  described 
on  page  75  is  necessary. 

The  patient  should  be  taught  to  examine  his  urine  for  sugar  every 
two  or  three  days.  At  the  slightest  appearance  of  sugar  he  should 
report  his  condition  to  the  physician,  and  a  fast  day  must  be  insti- 
tuted. Patients  should  be  encouraged  to  take  long  vacations,  to 
secure  abundance  of  sleep,  to  avoid  physical  and  mental  labor,  to 
shun  obesity  and  to  secure  sufficient  exercise. 

Joslin  gives  the  following  lists  which  are  of  especial  value : 
37 


Dt\ 


DIET  /A  DISEASE 


STRICT  DIET.     MEATS,  FISH,  BROTHS,   GELATINE,   EGGS,   BUTTER, 
OLIVE  OIL,  COFFEE,  TEA  AND  CRACKED  COCOA. 

Foods  arranged  approximately  according  to  per  cent,  of  Carbohydrates. 


Vegetables 

10  per  cent. 

15  per  cent. 

•~'u  per  ceni. 

5  per  cent. 
Lettuce                   Cauliflower 
Spinach                  Tomatoes 
Sauerkraut            Rhubarb 
String  beans         Egg  plant 

Onions 
Squash 
Turnip 
Carrots 

Green  peas 
Artichokes 
Parsnips 
Canned  lima 

Potatoes 
Shell  beans 
Baked  bea 
Green  corn 

Celery                     Leeks 
Asparagus             Beet  greens 
Cucumbers             Water  cress 

Okra 

beans 

Boiled  rice 

Mushrooms 
Beets 

Boiled 
macaroni 

Brussels                 Cabbage 

sprouts               Radishes 
Sorrel                     Pumpkin 
Endive                    Kohlrabi 

Dandelions             Broccoli 

Swiss  chard          Vegetable 

Sea  kale                     marrow 

Fruits 

Lemons 

Apples 

Plums 

Ripe   olives    (20  per   cent,   fat) 

Oranges 

Pears 

Bananas 

Grape  fruit 

Cranberries 
Strawberries 

Apricots 
Blueberries 

Blackberries 

Cherries 

Gooseberries 

Currants 

Peaches 

Raspberries 

Pineapple 
Watermelon 

Huckleberries 

Nuts 

Brazil  nuts 

Almonds 

Peanuts 

Butternuts 

Black  walnuts 

Walnuts  (Eng.) 

40  per  cent. 

Pignolias 

Hickory 
Pecans 

Beechnuts 
Pistachios 

Chestnuts 

Filberts 

Pinenuts 

MiSCEIXANEOUS 

Unsweetened        and        unspiced 
pickles,    clams,    oysters,    scal- 
lops, liver,  fish  roe. 

Reckon    actually    available    carbohydrates    in 
vegetables    of    5    per    cent,    group    as    3    per 
cent.,  of  10  per  cent,  group  as  6  per  cent. 

Contain  Approximately 

Oatmeal,  dry  weight    

Meat     ( uncooked )      

Meat     ( cooked )      

Broth     

Potato      

Bacon    ( cooked )     

Cream,  40  per  cent 

Cream,  20  per  cent 

Milk     

Bread     

Butter 

Egg    (one)    

Brazil   nuts    

Orange    ( one )     

Grapefruit    ( one)     

Vegetables,  5-10  per  cent,  groups   

1  gram  protein,  4  calories. 

1  gram  fat,  9  calories. 

6.25  grams  protein  contain  1  gram  nitrogen. 


Protein. 
5 

Pat. 
2 

Carbo- 
hydrates, 
Grams. 
20 

Calorie 
110 

6 

2 

0 

40 

8 

3 

0 

60 

0.7 

0 

0 

3 

1 

0 

6 

30 

5 

15 

0 

155 

1 

12 

1 

120 

1 

6 

1 

60 

1 

1 

2 

20 

3 

0 

18 

90 

0 

25 

0 

240 

6 

5 

0 

75 

5 

20 

2 

210 

0 

0 

10 

40 

0 

0 

10 

40 

0.5 

0 

1 

6 

DISEASES  IN  WHICH   DIET  IS  A  PRIMARY  FACTOR 


579 


30  grams   (g)   or.  cubic  centimeters   (c.em. )  =  1  uuiite. 

1  gram  carbohydrate,  4  calories. 

1  gram  ak-oliol,  7  calories. 

1  kilogram  =  2. 2  pounds. 

A  patient  "at  rest"  requires  25  to  30  calories  per  kilogram  body  weight. 


VEGETABLES. 
In  order  of  their  Carbohydrate  Contents,  from  lowest   to  highest. 

Edible  Portion 

Cucumbers,    fresh    

Cucumber   pickles    

Asparagus,   canned    

Celery,    fresh    

Endive,   fresli 

Spinach,   fresh    

Asparagus,    fresh     

Lettuce,    fresh     

Brussels  sprouts,  canned   

Brussels   sprouts,   fresh    

Olives,    ripe     

Okra,   canned    

Rhubarb,    fresh    

Sorrel,    fresh     

Watercress,    fresh    

String  beans,  canned    

Tomatoes,    fresh     

Tomatoes,   canned    

Sauerkraut      

Artichokes,    canned    

Eggplant,   fresh    

Pumpkin,   fresh    

Kohl  Rabi,  fresh    

Cabbage,   fresh    

Cauliflower,    fresh    

Radishes,    fresh    

Pumpkin,    canned    

Mushrooms,    fresh    

Okra,   fresh    

Turnips,   fresh    

Olives,    green     

Oyster  plant,  fresh    

Squash,    fresh     

Carrots,    fresh    .  ; 

String   beans,   fresh    

Beets,    fresh    

Green  peas,  canned    

Onions,    fresh    

Squash,    canned    

Green   peas,   fresh    

Parsnips,    fresh    

Artichokes,    fresh     

Potatoes,    fresh    

Green  corn,  canned   

Green   corn,   fresh    

Potatoes,    boiled     


Fat, 

Carbo- 

Calories, 

per  cent. 

per  cent. 

hydrate, 
jjer  cent. 

per 
100  Gms. 

U.8 

0.2 

2.5 

15 

0.5 

0.2 

2.5 

15 

1.5 

0.1 

2.8 

19 

L4 

0.0 

3.0 

18 

1.0 

0.0 

3.0 

16 

2.1 

0.5 

3.1 

26 

1.8 

0.2 

3.3 

22 

1.3 

0.4 

3.3 

22 

1.5 

0.1 

3.4 

21 

1.4 

0.1 

3.5 

21 

1.4 

21.0 

3.5 

215 

0.7 

0.1 

3.6 

18 

0.6 

0.7 

3.6 

24 

0.7 

0.7 

3.7 

25 

0.7 

0.7 

3.7 

25 

1.1 

0.1 

3.9 

23 

0.8 

0.4 

3.9 

23 

1.2 

0.2 

4.0 

23 

1.5 

0.8 

4r4 

32 

0.8 

0.4 

5.0 

24 

1.2 

0.2 

5.1 

29 

1.0 

0.1 

5.2 

27 

2.0 

0.1 

5.5 

33 

2.1 

0.4 

5.8 

36 

1.6 

0.8 

6.0 

39 

1.3 

0.0 

6.6 

33 

0.8 

0.2 

6.7 

33 

3.5 

0.4 

7.0 

46 

1.6. 

0.2 

7.4 

39 

1.3 

0.2 

8.1 

40 

0.8 

20.2 

8.5 

226 

4.3 

0.3 

8.8 

56 

1.7 

0.5 

9.0 

49 

1.1 

0.4 

9.2 

45 

2.2 

0.4 

9.4 

51 

1.6 

0.1 

9.7 

46 

3.6 

0.2 

9.8 

57 

1.7 

0.4 

9.9 

52 

0.9 

0.5 

10.5 

51 

7.0 

0.5 

16.0 

99 

1.6 

0.5 

16.5 

80 

2.6 

0.2 

16.7 

81 

2.2 

0.1 

18.4 

81 

2.8 

1.3 

19.3 

103 

3.0 

1.1 

19.7 

103 

2.5 

0.1 

20.9 

97 

580 


Edible  Portion 

Grapefruit      

Watermelon     

Strawberries      

Alligator    pears    .  .  .  . 

Lemons     

Muskmelons     

Peaches     

Pineapple     

Blueberries     

Lemon   juice    

Cranberries      

Blackberries    

Oranges    

Raspberries    

Gooseberries     

Apricots     

Whortleberries    

Pears     

Apples     

Huckleberries    

Cherries      

Grapes     

Bananas      


DIET  IN  DISEASE 

FRUITS. 
ohydrate  Contents,  f 

Protein, 
per  cent. 

rom    lowest 

Fat, 
per  cent. 

0.2 
0.6 
10.2 
0.6 
0.0 
0.1 
0.3 
0.3 

0.6 
1.0 
0.2 
1.0 
0.0 
0.0 
3.0 
0.3 
0.3 
0.6 
0.8 
1.6 
0.6 

to  highest. 

Carbo-           C 
hydrate, 
per  cent.        1( 

5.0 

6.7 

6.8 

6.8 

8.5 

9.3 

9.4 

9.7 

9.8 

9.8 

9.9 
10.9 
11.6 
12.6 
13.1 
13.4 
13.5 
14.1 
14.2 
16.6 
16.7 
19.2 
22.0 

alories 

per 
)0  Gm 

20 

0.4 

31 

l.O 

38 

:.o 

127 

1.0 

45 

0.6 

40 

0.7 

42 

0.4 

44 

0.1 

43 

40 

0.4 

48 

1.3 

60 

0.8 

53 

1.7 

69 

1.0 

58 

1.1 

60 

0.7 

80 

0.6 

65 

0.4 

65 

0.6 

76 

1.0 

80 

1.3 

100 

1.3 

101 

NUTS. 

In  order  of  their  Carbohydrate  Contents,  from    lowest  to  highest. 

FntRTF    PoRTin^T  Protein.  Fat.  v^^'"*'?"  Calories 

LdiblE   PoBTION  percent.  percent.  ^l^Z^J  .J'cr... 

'  per  cent.  lOo  Gms. 

Butternuts     27.9  61.2  3.5  698 

Pinenuts    (Pignolia)    34.0  50.0  6.0  630 

Brazil   nuts     17.0  67.0  7.0  720 

Filberts     15.6  65.3  13.0  725 

Hazel  nuts   18.0  64.0  14.0  720 

Pecans     9.6  70.3  15.3  757 

Almonds     21.0  55.0  20.0  668 

Peanuts    25.8  38.6  24.4  365 


FISH 

In  order  of  their  Carbohydrate  Contents,  from   lowest  to  highest. 

Edible    PoRTIOiN                                                Protein  Fat. 

per  cent.  per  cent. 

Shad   roe    20.9  3.8 

Shell  Fish,  etc. 

Crabs      16.6  2.0 

Clams      8.6  1.0 

Oyster,    solids     6.0  1.3 

Scallops      14.8  0.1 


Carbo- 
hydrate, 
per  cent. 
2.6 

1.2 
2.0 
3.3 
3.4 


Calories, 

per 
100  Gms. 

130 


101 
53 
51 
75 


Edible  Poetion 


MEATS. 

Protein, 
per  cent. 


Bacon      10.0 

Bacon,   crisp    10.0 

Beef,  round,  very  lean,  fresh   20.8 

Chicken,   fresh    ". 22.8 


Fat, 
per  cent. 

67.2 
0.0 

5.8 
1.8 


Carbo- 
hydrate, 
per  cent. 


Calories, 

per 
100  Gms. 

666 

41 

135 

110 


DISEASES  l.\    WBiVH  DIET  IS  A  PRIMARY  FACTOR 


581 


Edible  Portion 

Ham,  very   lean    

l.amb,   very   lean,   fresh    . 
Mutton,  very  lean,  fresh 

Pork,   lean,  fresh    

Veal,  very   lean,   fresh    .  . 

Bass,    fresli     

Bluetish,   fresh    

Cod,  fresli      

Flounder,    fresh    

Halibut,    fresh     

Salmon,  fresh    

Shad   roe,   fresh    

Shad,   whole,   fresh    


Protein, 
per  cent. 

Fat, 
per  cent. 

Carbo- 
hydrate, 
per  cent. 

Calories, 

per 
100  Gms, 

20.2 

20.8 

276 

19.1 

12.4 

193 

19.1 

12.4 

193 

19.0 

13.0 

199 

21.0 

3.6 

120 

ISH. 
20.6 

2.0 

103 

19.0 

1.2 

90 

15.8 

0.4 

70 

13.9 

0.6 

62 

18.4 

5.2 

124 

22.0 

12.8 

213 

20.9 

3.8 

2.6 

130 

18.8 

9.5 

165 

DAIRY  PRODUCTS,  ETC. 

As  Purchased 

Edible  Portion 

Butter     82.4  765 

Cheese,   American,   pale    28.8               35.9  452 

Brie     15.9               21.0  1.4               266 

Cream.  Imt'n  full    25.9               31.7  401 

Roquefort     22.6               29.5  1.8               375 

Swiss     27.6               24.9  443 

Cream 

Verv    tliick     50.0  4.4                483 

Average      2.5                18.5  4.5                201 

Milk 

Whole     3.3                 4.0  5.0                 71 

Skimmed 3.4                 0.3  5.1                 37 


Caloric  Equivalent  of  10  gms.  of  Steak  in  Carhohydrate-Free  Meat 

Food  Gms.  F*^*-                 Protein. 

gms.  gms. 

Steak     10  1.0  2.4 

Roast  beef    5  ■              1.4  1.1 

Tongue     7  1.4  1.6 

Lamb    chop     o  1.5  1.1 

Roast    lamb    8  1.3  1.6 

Sweetbreads      11  0.1  4.4 

Boiled    ham    7  1.4  1.5 

Fried   ham    5  1.7  1.1 

Roast    pork     9  0.9  2.6 

Bacon 9  1.7  0.9 

Chicken     11  1.0  2.4 

Duck      9  1.3  1.8 

Guinea   hen    12  0.8  2.8 

Squab     9  1.1  2.1 

Turkey 7  1.3  2.0 

Bluefish     13  0.6  3.5 

Halibut 16  0.7  3.3 

Mackerel      15  1.0  2.5 

Sardines   in  oil    7  1.4  1.6 

Vegetables  Allowed  on  ''Carhohydrate-Free'^  Diet. 

Asparagus  Celery 

Brussels  sprouts  Cucumbers 

Cabbage  Egg-plant 

Cauliflower  Endive 


or  Fish. 

Calories. 

19 
18 
20 
18 
20 
19 
19 
20 
19 
20 
19 
19 
19 
19 
20 
20 
20 
20 
20 


582  DIET  IN  DISEASE 

Greens  '  Sorrel 

Kohl-rabi  Spinach 

Lettuce  String-beans 

Pickles  (sour)  Swiss  chard 

Rhubarb  Tomatoes 

Sauerkraut  Water-cress 

Approximate  Equivalent  in  Alcohol  of  30  c.c.  (1  ounce)  of  Whisky  in  Liquors 
Containing  2%  or  Less  of  Carbohydrate. 

_  Household 

^•'^-  Measure. 

Gin,  rum,  brandy    30  2  Tbsp. 

Claret,  Burgundy,  Hock,  Rhine  and  Moselle  wines..    .130-160  |  Tumbler 

In  the  severer  forms  of  diabetes  it  is  well  to  omit  bread  and  use 
some  substitute.  Those  who  can  afford  it  will  find  the  Huntley  and 
Palmer  Akoll  Biscuits,  Lyster  Diabetic  Flour,  Hepco  Flour  (Wauke- 
sha Health  Products  Co.,  Waukesha,  Wis.)  Barker's  Gluten  Flour, 
Brand  A,  and  the  Casoid  products  satisfactory.  Very  helpful  lists 
of  the  various  diabetic  products  wull  be  found  further  on.  Patients 
ask  so  many  questions  concerning  these  foods,  many  of  which  are  un- 
suited,  that  the  lists  will  be  found  valuable  as  a  check  on  what  to  use. 

Mosenthal  has  devised  some  lists  which  are  very  valuable  in  the 
treatment  of  severe  diabetes  and  which  he  says  represent  so  many 
milestones  in  the  progress  of  the  patient.  They  contain  specified 
amounts  of  protein  and  are  free  from  carbohydrates.  Thej"  should 
not  be  used  one  after  the  other,  but  the  change  from  one  to  the  next 
made  gradually. 

These  diets  were  constructed  after  studying  the  nitrogen  balance 
on  patients  on  a  carbohydrate-free  diet.  Mosenthal  believes  that  not 
onl}"  should  the  patient  be  kept  sugar  and  acid  free,  but  the  nitrogen 
equilibrium  must  also  be  maintained.  With  the  carbohydrates 
eliminated  from  the  diet,  except  as  contained  in  green  vegetables,  it 
was  found  that  in  order  to  furnish  food  that  was  palatable  over  long 
periods  of  time  the  number  of  grams  of  fat  must  be  near  or  equal 
the  number  of  grams  of  protein.  In  the  average  individual  it  was 
found  possible  to  get  nitrogen  equilibrium  on  a  diet  of  from  1500  to 
1700  calories  and  the  practical  deduction  is  that  slightly  over  these 
amounts  should  be  ingested  on  a  carbohydrate  free  diet  and  if  the 
tolerance  of  the  patient  permits,  additional  carbohydrate  should  be 
added. 

THE  JOHXS  HOPKINS  HOSPITAL 

STANDARD  CARBOHYDRATE-FREE  DIET. 

Diabetes  MelUtus. 
Alcohol,         Protein,      Nitrogen,  Fat,  wiraTp  Total 


gms.  gms.  gnis.  gms. 


Breakfast . 


^•-drate,        ^alori  s. 
gms. 


2  eggs    13.2  2.1  12.  166 

Ham,  90  gms 18.2  2.9  20.2  262 

Coffee,    with    45    gms. 

cream     1.1  .2              8.3  2.0  91 


DISEASEii  I\  WHICH  DIET  IS  A  PRIMARY  FACTOR 


583 


Alcohol, 
gms. 


Butter,    15   gms.   to   be 
used   in   cooking    .  .  . 
Eggs    if    no    biscuit 
or  bread  is  taken. 
Dinner : 

Any    clear    soup    

-  Meat  or  fish,  200  gms. 

1  Green  vegetable  from 

list  as  desired    

Salad  witli  15  gms.  of 
oil    in    dressing    .... 

Cream   clieese,   30   gms. 

3  Whiskey,  30  c.cm,    .  . 

Demitasses  of  coffee 

Butter,  30  gms.  on  fish, 
meat  and  green  vege- 
tables if  no  biscuit 
or  bread  is  taken  .  . 
Supper  : 

2  Meat  or  fish,  120  gms. 
1  Green   vegetable  from 

list  as  desired    

3  Whiskey,  30  c.cm.    .  . 
Butter,    15    gms.    with 

green  vegetables, 

meat  or  fish  if  no  bis- 
cuit     or      bread      is 

taken      

Tea  with  15  gms.  cream 
Bedtime: 

Bouillon    with     1     raw 


ego" 


12 


12 


Protein, 
gms. 


9.6 


Nitrogen,        Fat, 
gms.  gins. 


Trace 


12.8 


.2 

Trace 

25.6 

24.0 

3.8 

24.0 

Trace 

Trace 

Trace 

Trace 
Trace 


1.5 


12.8 

2.8 


6.0 


Carbo- 
hydrate, 
gms. 


Trace 


0.7 


Total 
Calories. 


119 


3.0 
40.0 

.5 

6.4 

Trace 
40.0 

12 
536 

Trace 

Trace 

Trace 

Trace 

15 

Trace 
5.4 

Trace 
.9 

15.0 
11.1 

Trace 

.7 

150 
129 

83 

238 

321 

15 
83 


119 
30 


95 


24  115  18  191  4  2564 

1  Vegetables  allowed.  (These  may  be  prepared  or  served  with  pepper,  salt, 
mustard,  oil,  vinegar,  butter  or  any  fat.)  Asparagus,  beet-greens,  Brus- 
sels sprouts,  cabbage,  cauliflower,  celery,  chicory,  cucumbers,  egg-plant,  endives, 
kohlrabi,  leeks,  lettuce,  okra,  pumpkin;  radishes,  rhubarb,  salsify,  sauerkraut, 
spinach,  string-beans,  tomatoes,  vegetable  marrow. 

2  Stew  or  liver  are  not  to  be  served  as  "meat"'  in  this  diet.  No  sauces  or 
gravies  thickened  with  flour  are  allowed. 

3  Instead  of  30  c.cm.  of  whiskej',  30  c.cm.  of  brandy  or  120  c.cm.  of  claret  or 
sour  white  wine  may  be  used. 


Carhohijdrate-Free  Diet,  500  Calories. 

POOD  ^w'  Protein,  Pat,  CH., 

c.cm.  S"**-  S™**-  S™*- 

Breakfast : 

One    egg     50  6.6  6.0  0 

Bacon  1     40  4.2  7.6  0 

Black  coffee     

Dinner: 

Broth      150  3.3  0  3  0 

Steak  2      40  9.4  4.1  0 

Vegetables  3   200  2.0  0  6.0 

Butter     5  0.1  4.3  0 

Black  coffee     


Calories 

Calories. 

per 

Meal. 

83 

88 

171 

16 

77 

33 

40 

166 


584 


DIET  ly  DISEASE 


Supper  : 

Broth    150  3.3  0.3  0  16 

Steak  •.;    40  D.4  4.1  0  77 

Vegetables  3     200  2.0  0  6.0  33 

Butter     5  0.1  4.3  0  40 

Plain  tea   166 

40.4  31.0  12.0  503 

1  The  bacon  is  weighed  uncooked.     Tlie  fat  and  protein  content  is  calculated 

for  the  cooked  product. 

-  The    caloric    equivalent    of    other    carbohydrate-free    meat    or    fish    should    be 

frequently  substituted  from  the  accompanying  list,  to  furnish  variety  in  the  diet. 
3  Two  or  three  different  vegetables  should  be  chosen   from  the  accompanying 

list,  which  tabulates  the  vegetables  containing  5%  or  less  of  carbohydrates. 

Carbohydrate-Free  Diet,  1000  Calories. 

Gms.  T.     »  •  -El  t  /^  tr                              Calories 

c.?L.  -^•"  '-  '.msV        calories.        ^pe.^ 

Breakfast : 

Eggs    (2)    100  13.2  12.0  0            166 

Bacon  1     50  5.3  9.6  0           111 

Butter     5  0.1  4.3  0             40 

Black   coffee    317 

Dinner : 

Broth    150  3.3  0.3  0             16 

Steak  2      100  23.9  10.2  0           193 

Vegetables  3     200  2.0  0  6.0             33 

Olive   oil    10  0  10.0  0             93 

Butter     10  0.1  S.6  0             80 

Black   coffee    415 

Supper  : 

Broth    150  3.3  0.3  0             16 

Steak  2    75  17.9  7.7  0           145 

Vegetables  a     200  2.0  0  6.0              33 

Butter     10  0.1  8.6  0             80 

Tea    (plain)     274 

71.2  71.6  12.0  1006 

1  The  bacon  is  weighed  uncooked.  The  fat  and  protein  content  is  calculated 
for  the  cooked  product. 

2  The  caloric  equivalent  of  other  carbohydrate-free  meat  or  tish  should  be 
frequently  substituted  from  the  accompanying  list,  to  furnish  variety  in  the 
diet. 

3  Two  or  three  diflerent  vegetables  should  be  chosen  from  the  accompanying 
list,  which  tabulates  the  vegetables  containing  5%  or  less  of  carbohydrates. 


Carbohydrate-Free  Diet,  1500  Calories. 

vnOTi  ^^^'  Protein,  Fat,  CH., 

^  ccm.  S'"^-  S^^-  S^^- 
Breakfast: 

Eggs     (2)     100  13.2  12.0  0 

Baconi     60  6.4  11.5  0 

Butter     10  0.1  8.6  0 

Black  coffee     

Dinner : 

Broth      150  3.3  0.3  0 

Steak  2    140  33.5  14.3  0 


Calories. 


166 
133 

SO 


16 

270 


Calories 

per 

Meal. 


379 


DISEASES  7-V  WHIC 

Gms. 

POOD  or 

c.cm. 

Vegetables  a     200 

Cream   cheese    20 

Olive    oil    15 

Butter     15 

Black  coffee     

Supper  : 

Broth      150 

One  egg    50 

Steak  2      100 

Vegetables  3      200 

Butter     15 

Tea    (plain)     


DIET  IS 

A   riUMARY 

FACTOR 

585 

Protein, 
gms. 

Fat, 
gms. 

CH., 
gms. 

Calories. 

Calories 

per 

Meal 

2.0 

0 

6.0 

33 

5.2 

6.7 

0.5 

86 

0 

15.0 

0 

140 

0.2 

12.9 

0 

120 

665 

.3.3 

0.3 

0 

16 

tj.6 

U.O 

0 

83 

23.S> 

10.2 

0 

193 

2.0 

0 

6.0 

33 

0.2 

12.9 

0 

120 

99.9 


110.7 


12.5 


445 


1489 


1  The  bacon  is  weighed  uncooked.  The  fat  and  protein  content  is  calculated 
for  the  cooked  product. 

-  The  caloric  equivalent  of  other  carbohydrate-free  meat  or  fish  should  be 
frequently  substituted  from  the  accompanying  list,  to  furnish  variety  in  the 
diet. 

3  Two  or  three  different  vegetables  should  be  chosen  from  the  accompanying 
list,  which  tabulates  the  vegetables  containing  5%  or  less  of  carbohydrates. 


Carbohydrate-Free  Diet,  2000  Calories. 

POOn                               ^^'"          Protein,         Pat,              C-H..  ^  ,     .           Calories 

Breakfast : 

Eggs     (2)     100           13.2            12.0                0  166 

Ham      75           15.2            16.8                0  219 

Butter     15             0.2            12.9                0  120 

Vegetables  3     100             1.0                0             3.0  16 

Black  coffee     521 

Dinner  : 

Broth    160             3.5             0.3                0  17 

Steak  2      160           38.2           16.3                0  308 

Vegetables  3     300             3.0                0             9.0  49 

Cream   cheese    30             7.8           10.1             0.7  129 

Butter     20             0.2            17.2                0  160 

Olive  oil   15             0              15.0                0  140 

Black  coffee     803 

Supper : 

Broth      160             3.5             0.3                0  17 

Eggs     (2)     100           13.2            12.0                0  166 

Steak  2      140           33.5            14.3                0  270 

Vegetables  3     300             3.0                0             9.0  49 

Butter     20             0.2   -        17.2                0  160 

Tea    (plain)     662 

135.7         144.4           21.7  1986 

2  The  caloric  equivalent  of  other  carbohydrate-free  meat  or  fish  should  be 
frequently  substituted  from  the  accompanying  list  to  furnish  variety  in  the 
diet. 

3  Two  or  three  different  vegetables  should  be  chosen  from  the  accompanying 
list,  which  tabulates  the  vegetables  containing  5%  or  less  of  carbohydrates. 

Green  or  Vegetable  Days. — Von  Noorden  suggested  the  use  of 
vegetable  days  and  they  are  of  service  in  giving  carbohydrate-free 

and  loiv  protein  days  without  so  much  discomfort  to  the  patient.     A 
sample  of  such  a  diet  is  as  follows: 


586 


DIET  IX  DISEASE 


THE  JOHNS  HOPKINS  HOSPITAL  GREEX  DAY  DIET. 

Alcohol,  Protein,       Nitrogen.  Pat.  hydrate  '^°*^' 

gms.  gms.  gms.  gms.  "gms.  '     Calories. 

Breakfast: 

1  egg,  boiled  or 
poaclied     6.G  1.1  6.0  83 

Cup  of  black  coffee 
Dinner: 

Spinach,  with  a  hard- 
boiled    egg 6.6  1.1  6.0  Trace  83 

Bacon,   15  gms 1.5  .2  9.8  100 

Salad,    with     15     gms. 

of  oil    Trace  Trace  15.0  Trace  150 

Whisky,  30  c.cm 12 

Supper  : 

1  egg,  scrambled,  with 
tomato  and  a  little 
butter     6.6  1.1  6.0  83 

Bacon,  15  gms 1.5  .2  9.8  100 

Cabbage,  cauliflower, 
sauerkraut.  string- 
beans    or    asparagus.  Trace  Trace        Trace  Trace  15 

Whisky,  30  c.cm 12  83 

Bedtime  : 

Cup     of     beef     tea     or 

chicken    broth     3.0  .5  Trace  12 

Total      24  26.  4.  53.  Trace  792 

Sodium  bicarbonate,  15  to  30  gms.  in  the  24  hours. 

Oatmeal  Diet. — Von  Noorden  introduced  the  oatmeal  diet  and 
good  results  were  obtained  by  it,  but  they  were  probably  all  due  to 
the  small  amount  of  food  taken  rather  than  any  specific  action  of  the 
oatmeal.  It  forms,  however,  a  valuable  addition  to  the  diabetic  diet 
and  is  much  relished  by  some  patients.  Oatmeal  days  are  not  much 
used  nowadays,  but  a  sample  diet  is  appended. 


OATMEAL  DAY  DIET  THE  JOHNS  HOPKINS  HOSPITAL 

Carbo- 
hydrate, 
gms. 
170 


Alcohol, 

Protein, 

Nitrogen. 

Fat. 

gms. 

gms. 

gms. 

gms. 

Oatmeal 

250  gms.    .  .  . 

40.0 

6.4 

15. U 

Butter. 

250 

Sms 

2.5 

.4 

213  0 

Whites 

of  six  eggs    .  . 

25.0 

4.0 

.4 

Whisky 

90  c.cm. 

or 

Brandy 

70  c.cm. 

or 
Claret 

450  c.cm. 

36 

or 

Sour  White 

Wine 

450  c.cm. 

2  cups  of  black  coffee 


Total 
Calories. 

1000 

1990 

105 


276 


36  68  11  228  170         3371 

Cook  the  oatmeal  thoroughly  in  water  for  two  hours.  The  butter  and  egg 
whites  must  be  well  stirred  in  when  the  oatmeal  is  nearly  done.  Use  salt  and 
pepper  as  desired.  This  may  be  eaten  as  gruel,  mush,  or  fried  mush.  It  should 
be  divided  into  7  equal  parts,  one  part  to  be  taken  every  two  liours.  The  black 
coffee,  sour  white  wine,  claret,  whisky,  or  Ijrandy  may  be  taken  at  any  time 
throughout  the  day. 


DISEASES  IX    WHICH  DIF/V  IS  A  PRIMARY  FACTOR  587 

Other  Diet  Cures. — In  former  days  special  diet  cures  were  much 
in  vogue.  Details  of  many  will  be  found  in  the  first  four  editions 
of  this  book.  Among-  them  the  Potato  Cure  of  Mosse,  the  Yolk  Cure 
of  Stern,  the  rye  bread  cure,  the  milk  cure,  and  others.  The  potato, 
the  banana  and  rye  bread  are  useful  as  they  satisfy  the  appetite 
better  than  ordinary  bread  in  the  using  of  which  there  is  a  great 
tendency  to  eat  too  much.  The  soy  bean  makes  a  welcome  change 
in  the  diet. 

Emergency  Diet. — Persons  suffering  from  severe  or  even  moderate 
diabetes  should  be  instructed  in  regard  to  the  diet  in  case  emergency 
should  throw  them  on  their  own  resources  in  places  where  suitable 
food  cannot  be  obtained.  It  frequently  happens  that  diabetic  coma 
is  caused  by  the  patient  starving  rather  than  take  what  he  believes 
to  be  unsuitable  food,  or  it  may  be  caused  by  gastro-intestinal  dis- 
turbance, brought  on  by  the  use  of  poorly  prepared  foods.  In  case 
of  emergency  the  patient  should  be  instructed  to  try  and  secure  a 
diet  consisting  of  eggs,  cheese,  bacon,  butter,  coffee  or  tea,  and  green 
vegetables.  If  the  digestion  is  upset,  oatmeal  or  milk,  or  a  combina- 
tion of  the  two,  will  often  be  found  to  be  the  best  diet  the  patient  can 
use  until  he  is  again  placed  in  circumstances  where  his  diet  may  be 
carefully  looked  after. 

Alcohol. — The  question  of  alcohol  for  the  diabetic  is  the  subject  of 
diverse  opinions  by  the  profession.  Von  Noorden  favors  the  mod- 
erate use  of  alcohol  for  the  following*  reasons : 

(a)  It  is  useful,  when  a  fat  and  meat  diet  is  ordered,  in  preventing 
disagreeable  sensations  after  the  taking  of  fat,  and  consequently 
assists  the  patient  in  taking  his  diet. 

(b)  Alcohol  furnishes  the  diabetic  with  a  valuable  fuel,  as  each 
gram  of  alcohol  gives  off  7  calories  of  heat ;  or  if  14.3  gm.  of  alcohol 
are  given,  10.75  gm.  of  fat  may  be  omitted  from  the  diet.  This  can 
be  utilized  only  to  a  limited  extent,  as  alcohol  consumed  in  large  quan- 
tities is  productive  of  great  harm.  Sixty  grams  (2  ounces)  of  alcohol 
daily  may  be  looked  upon  as  an  average  amount,  and  is  not  to  be 
exceeded  unless  the  patient,  through  long  years  of  drinking,  has 
acquired  a  tolerance  for  it. 

(c)  Alcohol  is  a  good  nervine  and  a  useful  heart  tonic.  It  is 
valuable  in  the  hands  of  a  man  who  can  individualize,  but  in  the 
hands  of  the  routinist  and  generalizer  it  becomes,  according  to  Von 
Noorden,  a  two-edged  sword. 

If  alcohol  is  used  the  lighter  forms  of  alcoholic  drinks  are  to  be 
preferred. 

One  hundred  grams  of  alcohol,  for  the  most  part  without  admixture 
of  carbohydrates,  are  contained  in: 

2500  c.c.  Pilsener  beer  (1  liter) — contains  35  gm.  carbohydrate, 
dextrin,  and  maltose. 


588  DIET  IN  DISEAf^E 

1200-1500  c.c.  white  table  wine  (Moselle,  Rheingar,  Pfalz,  Baden, 
etc.) 

1100-1300  c.c.  medium  sorts  of  claret. 

1000-1200  c.c.  tine  red  Burgundy. 

1800-2200  c.c.  well-fermented  fruit-wine   (extra  dry). 

280  c.c.  rum. 

280  c.c.  old  rye  whisky. 

210  c.c.  whisky. 

200  c.c.  arrack. 

180  c.c.  cognac. 

180  c.c.  cherry  brandy. 

Acidosis  and  Diabetic  Coma. — The  management  of  acidosis  and 
diabetic  coma  are  still  the  matters  of  some  discussion.  The  Allen 
method  of  starvation  outlined  generally  above,  will  prevent  or  control 
the  acidosis,  but  not  in  aJl  cases.  Where  the  patient  is  not  uncon- 
scious and  the  C0^>  pressure  not  below  15  mm.  the  following  treatment 
may  be  tried  and  is  usually  effective.  If  the  patient  is  unconscious 
and  the  CO,  pressure  below  15  mm.  the  same  measures  may  be  tried, 
but  the  prognosis  is  bad. 

Special  nurses  are  essential  as  the  patient  must  be  kept  in  bed  and 
warm.  The  bowels  are  moved  copiously  by  enemata  of  warm  water. 
There  is  a  difference  of  opinion  regarding  the  use  of  purgatives  for 
this  purpose  and  whether  or  not  they  should  be  used  will  have  to  be 
determined  by  further  observation.  Calomel  and  Epsom  salts  are 
most  frequently  prescribed.  The  danger  in  their  use  is  in  setting  up 
a  diarrhea.  If  alkalis  have  been  given  they  should  be  omitted  at  the 
rate  of  30  gms.  a  day ;  if  they  have  not  been  given  they  should  be 
avoided.  Joslin  suggests  a  liter  of  fluid  by  mouth  or  by  rectum  every 
six  hours,  and  if  this  amount  cannot  be  got  into  the  patient  salt 
solution  to  make  up  the  amount  should  be  given  intravenously. 

As  regards  food,  he  continues  the  fast  if  the  patient  is  fasting, 
but  if  he  has  been  on  a  full  diet  he  gives  one  gram  of  carbohydrate  for 
each  kilo  of  body  weight  each  twenty-four  hours  in  the  form  of  orange 
juice  or  oatmeal  gruel  made  with  water.  Digitalis  and  caffein  are 
used,  if  needed.  Alcohol  may  be  used,  but  here  again  there  is  a 
difference  of  opinion  as  to  its  value;  the  present  tendency  is  to  use 
it  sparingly,  if  at  all. 

Exercise. — Here  again  there  are  differences  of  opinion ;  as  in 
former  days  the  patients,  if  severelj^  affected,  were  kept  at  rest. 
Allen,  as  the  result  of  experimental  work  on  dogs,  recommends  con- 
siderable exercise.  Each  individual  must  be  exercised  as  aft'ects  him 
most  favorably,  some  not  at  all,  some  to  the  point  of  pleasurable 
fatigue,  and  some  severely.  By  observing  the  effects  of  exercise  on 
the  heart  and  pulse  rate,  and  on  the  sugar  in  the  urine,  and  in  the 
blood,  if  it  is  possible  to  make  tests,  a  fair  judgment  can  be  arrived  at 
regarding  the  amount  of  exercise. 


DIi<EASEi<  I\    WHICH  DIET  IS  A    I'lilMMlY  FACTOR  589 

Diabetes  in  Children. — There  seem  to  be  two  types,  one  not  very- 
severe  and  with  a  favorable  prognosis,  and  one  very  severe  and  of 
bad  prognosis.  Every  ett'ort  should  be  made  to  maintain  the  child  on 
a  strict  diet  so  as  to  keep  the  urine  free  from  sugar  and  acid.  They 
may  show  remarkable  variations  in  their  ability  to  utilize  both  fats 
and  carbohydrates.  At  the  Rockefeller  Institute  the  diet  is  begun  at 
one  and  a  half  grams  of  protein  per  kilogram  of  body  weight,  one 
tenth  the  amount  of  carbohydrate  tolerated  and  fats  to  make  up  the 
deficiency  to  35  calories  per  kilogram  of  body  weight.  If  there  is 
any  tendency  to  acidosis  the  fats  must  be  cut  back  or  eliminated  and 
then  increased  again.  The  carbohydrates  are  then  built  up  one  food 
at  a  time  as  in  adults,  and  the  same  foods,  if  very  carefully  prepared, 
so  as  to  avoid  the  danger  of  diarrhea.  This  is  increased  until  the 
limit  of  tolerance  is  reached  and  then  the  carbohydrate  limit  is  cut 
in  half  and  the  proteins  increased  up  to  two  and  a  half  or  three 
grams  per  kilogram  of  body  weight.  An  effort  should  be  made  to 
gradually  work  up  to  50  calories  per  kilogram  of  body  weight.  The 
danger  seems  to  lie  more  in  over  feeding  than  in  under  feeding. 
Later,  if  the  tolerance  to  food  improves,  the  amount  may  be  in- 
creased. 

Diabetes  in  the  Aged. — Great  care  should  be  taken  here  as  in  other 
diseases,  not  to  upset  the  habits  of  a  life  time  and  to  make  whatever 
changes  that  may  be  necessary  as  gradually  as  is  consistent  with  the 
condition  of  the  patient.  Above  all  things,  acidosis  is  to  be  avoided 
and  if  the  gradual  restrictions  do  not  effect  the  necessary  changes 
the  fats  ma}^  be  cut  out  and  then  the  proteins  and  carbohj^drates  re- 
duced to  half,  if  necessary,  and  if  this  is  not  effective  the  protein  is 
omitted  and  then  the  carbohydrates  reduced  to  40  grams  and  the 
next  day  cut  in  half  and  the  following  day  omitted  entirely.  When 
the  urine  is  sugar  and  acid  free  the  diet  is  to  be  built  up  as  in  younger 
people,  keeping  within  the  tolerance. 

Diabetes  and  Nephritis  and  Arteriosclerosis. — In  patients  with 
renal  or  arterial  disease  there  is  a  greater  tendency  to  acidosis  and 
the  fat  in  the  diet  is  best  kept  at  a  low  level  or  eliminated  altogether 
and  the  protein  limited  to  about  one  gram  per  kilogram  of  body 
weight.  The  carbohydrates  maj'  be  allowed  according  to  the  tolerance 
shown  by  repeated  tests.  Any  regulation  of  the  diet  should  be  done 
very  gradually. 

Diabetes  and  Fevers. — During  fever  diet  cures  should  not  be  un- 
dertaken as  there  is  great  danger  of  bringing  on  an  acidosis.  The 
fats  should  be  low  or  eliminated,  the  proteins  sufficient  for  the  needs 
and  carbohydrates  according  to  the  patient's  tolerance. 

Diabetes  and  the  Bowel. — Constipation  should  be  avoided,  but 
great  care  should  also  be  taken  not  to  start  up  a  diarrhea.  Exercise, 
increasing  the  fruits  and  vegetables,  enemata,  mineral  oil  and,  if 
necessary,  laxatives  such  as  cascara,  rhubarb  or  aloin,  may  be  used. 


590 


DIET  lis:   DISEASE 


Diabetes  and  Surgical  Operations. — If  the  patient  is  free  from 
sugar  and  acid  operaticus  are  generally  well  borne.  The  presence  of 
sugar  is  not  as  serious  as  the  presence  of  acid.  The  problem  is  a 
serious  one  and  the  very  best  procedure  still  a  matter  of  discussion. 
There  is  no  question  about  the  advisability  of  giving  large  quantities 
of  fluid  both  before  and  after  the  operation.  After  the  operation 
the  Murphy  drip  may  be  used,  from  500  to  1000  e.c.  given  every 
six  hours.  The  latter  amount  if  the  urine  contains  either  sugar 
or  acid. 

The  administration  of  some  carbohydrates  before  the  operation  in 
these  cases  would  seem  advisable.  Joslin  advises  the  juice  of  two  or 
three  oranges,  or  45  grams  of  oatmeal  made  into  a  gruel  with  water. 
In  cases  of  acid  in  the  urine  before  the  operation,  or  even  after  it,  he 
advises  the  use  of  the  means  outlined  above  for  the  management  of 
threatened  coma.  The  present  day  tendency  is  not  to  give  alkalis 
unless  the  patient  has  been  taking  them  previously. 

Joslin  has  devised  a  number  of  charts  which  are  useful  in  making 
records  for  following  the  progress  of  a  case  of  diabetes.  These  may 
be  obtained  in  pads  from  Thomas  Groom  and  Company,  105  State 
Street,  Boston.  The  following  is  the  diet  prescription  blank  for 
severe  cases : 


Name 


Date 


Food 

Break- 
fast. 

Dinner. 

Supper. 

Total 
Grams. 

Carbo- 
hydrate. 

Protein. 

Fat. 

5%    \es 

10%   veg 

Esres     

Meat  Cooked    

Chicken    

Fish    

Bacon     

Butter    

Cream,  20% 

Cream,  40%    

Oatmeal     

Total  Grams 
MultiDlv  for  Calories 

4 

4 

9 

Tiitfll    Palorip 

a  — - 

DIET   LISTS   FOLLOWING   STARVATION   TREATMENT   OF   DIABETES   AS 
FOLLOWED  BY  THE  AUTHORS. 


Breakfast 

amt. 
Asparagus  . 2  htbsp. 
Cabbage  ...  3  htb.sp. 
Tea  or  coffee 


First  day  following  starvation  day. 

Dinner  Supper 

cal.  amt.       ral.  amt.       cal. 

23     Spinach     ...2  htbsp.      .57      String  beans  2  htbsp.      13 

5     Celery   3  stalks         8      Tomato  .  .  .  .i  small       23 

Tea  or  coffee  Tea  or  coffee 

Total  129 


I 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 


591 


Breakfast 


Egg    .  .  . 
Lettuce 


Breakfast 


^gg  ••• 
Spinach 
Tomato 


Breakfast 


^gg    

Asparagus 


Breakfast 


Tomato   .  . 
Asparagus 


Breakfast 


Egg    ••■ 
Spinach 


Breakfast 
Bacon 

Tomato   .  . 
Cream   .  .  . 


Breakfast 

Bacon    

Tomato   .  .  .  . 
String  beans 


Second  day  following  starvation  day. 

Dinner  Supper 

amt.       cal.  arnt.       cal.  ami.       cal. 

.one  83      Spinach    ...2htb8p.      57      Egg   one  83 

.three  Asparagus    .2htbsp.      23     Turnips     ...2htbsp.         6 

leaves        5      String  beans  2  htbsp.       13     Celery   3  small 

Tea  Coffee  stalks       8 

Coffee 
Total  278 
Third  day  following  starvation  day. 

Dinner  Supper 

amt.       cal.  amt.       cal.  amt.       cal. 

.  one  83      Egg   one  83    Egg    one  83 

.2  htbsp.  57  String  beans  2  htbsp.  13  Turnips  .  .  .  2  htbsp.  6 
.  I  small  23  Asparagus  .  2  htbsp.  23  Cabbage  ...  3  htbsp.  5 
Coffee  Tea  Coffee 

Total  376 
Fourth  day  following  starvation  day. 

Dinner  Supper 

amt.       cal.  amt.       cal.  amt.       cal. 

.one  83     Chicken     .  .  .small  Egg   one  83 

.2  htbsp.       23  serving  50     Asparagus    .2  htbsp.      23 

Tea  Cauliflower    2  htbsp.         8      String  beans  2  htbsp.       13 

Spinach     ...2  htbsp.      57  Coffee 

Tea  or  coffee  Total  340 

Fifth  day  following  starvation  day. 

Dinner  Supper 

amt.       cal.                                          amt.       cal.  amt.       cal. 

.one  83      Chicken  small  Egg    one  83 

•  Ismail        23                                  serving  50  Spinach     ...2  htbsp.       57 

.2  htbsp.      23      Brussels  Cucumber   ..8  thin 

Tea                           sprouts    ..2  htbsp.       25  slices         9 

Celery 3  small  Tea 

stalks        8  Total  360 
Coffee 

Sixth  day  follotving  starvation  day. 

Dinner  Supper 

amt.       cal.  amt.       cal.  amt.       cal. 

one  83     Steak  round .  small  85     Egg   one  83 

2  htbsp.      57      String  beans  2  htbsp.       13     Celery three  small 

Coffee  Tea  stalks       8 

Lettuce   ....  three 

leaves        5 
Tomato   .  .  .  .  i  small        23 
Coffee 
Total  450 
Seventh  day  following  starvation  day. 

Dinner  Supper 

amt.       cal.  amt.       cal.  amt.       cal. 

.2  slices  Chicken     ...small  Egg    one  83 

6"  long  323  serving  50      String  beans  2  htbsp.      23 

J  small        23      Turnips     ...2  htbsp.         6      Cream    1  tbsp.         54 

i  tbsp.         54      Asparagus    .2  htbsp.      23  Coffee 

Tea  Butter     1  ball        119 

Cream   1  tbsp.         54 

Coffee  Total  800 

Eighth  day  following  starvation  day. 

Dinner  Supper 

amt.       cal.                                          amt.  cal.                                          amt.  cal. 

2  slices      323      Lamb  chop    .one                        Egg    jne  83 

J  small        23                                 small  367      Spinach     ...2  htbsp  57 

2  htbsT).      23      Cucumbers   .8  thin  Cabbage    ...3  htbsp.  5 

slices  9 


592 

DIET  ly 

DISEASE 

Cream  .  . .  . 

.  1  tbsp. 

54 

Lettuce   . .  . 

.three 

Celery   .  .  . 

.  .3  stalks 

16 

Tea 

Celery   .... 
Milk     

leaves 
.6  small 

stalks 
.small 

5 
16 

Cofiee    . .  .  , 

. .  1  cup 

glass 

80 

Total  1040 

Nini 

t/i  day  foUoiciny  starvation 

day. 

Breakfast 

Dinner 

iiupper 

amt. 

cal. 

amt. 

cal. 

amt. 

cal. 

Egar   

one 

83 

Tend,  steak 

.small 

286 

Bacon    .  .  .  . 

.  .2  slices 

323 

Asparagus 

.2  htbsp. 

23 

Cabbage    . . 

.  3  htbsp. 

5 

Cucumbers 

.  8  slices 

9 

Butter 

.  1  ball 

119 

Turnips     .  . 

.2  htbsp. 

(> 

Lettuce   .  .  . 

.  3  leaves 

5 

Cream   .  .  .  . 

.  1  tbsp. 

54 

Tea    

.  1  cup 

Cream   .  .  .  . 

.  1  tbsp. 

54 

Cofifee    . .  .  . 

.  1  cup 

Cream   .... 

.  1  tbsp. 

54 

Coffee    .  .  . . 

.  1  cup 

Total  1015 

Tenth  day  after  starvation  day. 

Breakfast 

Dinner 

Supper 

amt. 

cal. 

amt. 

cal. 

amt. 

cal. 

Bacon    .  .  . . 

.2  slices 

323 

One  squab  . 

.small 

300 

Egg    

.one 

83 

Spinach     .  . 

.2  htbsp. 

57 

Cauliflower 

.2  htbsp. 

8 

Asparagus 

.2  htbsp. 

23 

Cream   .  .  .  . 

.  1  tbsp. 

54 

String  beans  2  htbsp. 

13 

Celery   .... 

.  6  small 

Butter 

.Iball 

118 

Cream   .... 

.  1  tbsp. 

54 

stalks 

16 

Coffee    

.1  cup 

Butter 

.  1  ball 

119 

Coffee    

.  1  cup 

Tea    

1  cup 

Butter 

Cream    .... 

.  1  ball 
.  1  tbsp. 

119 

54 

Total  1340 

Elei 

venth  day  aft 

'er  starvation  > 

day. 

Breakfast 

Dinner 

Supper 

amt. 

cal. 

amt. 

cal. 

amt. 

cal. 

Bacon    . . . . 

.2  slices 

323 

Steak  round 

small 

185 

y^EK 

.one 

83 

CauliHower 

.  2  htbsp. 

8 

Spinach     .  . 

.2  htbsp. 

Ol 

Cold  chicken  small 

Tomato   . .  . 

.  1  small 

46 

Brussels 

slice 

50 

Coffee    .  .  .  . 

.  1  cup 

sprouts    . 

.2  htbsp. 

25 

Lettuce   .  .  . 

. 3  leaves 

5 

Cream   .  .  .  . 

.  1  tbsp. 

54 

Cucumbers 

.8  thin 

Celerv   .... 

.6  small 

Butter     .  .  . 

.Iball 

119 

Tea     

slices 
.  1  cup 

9 

Coffee    

stalks 
.  1  cup 

16 

Cream   .... 

.1  tbsp. 

54 

Cream   .... 
Butter     .  .  . 

.  1  tbsp. 
.  1  ball 
Total  121 

54 

119 

[5 

Twelfth  day  afti 

?r  starvation  day. 

Breakfast 

Dinner 

Supper 

amt. 

cal. 

amt. 

cal. 

amt. 

cal. 

Kgg    

.one 

83 

Steak  tend. 

.small 

286 

Egg    

.one 

83 

Tomato   .  .  . 

.  1  small 

46 

Carrots   . .  . 

.3  htbsp. 

18 

Turnips     .  . 

2  htbsp. 

6 

Cream   . .  .  . 

.  1  tbsp. 

54 

Asparagus 

.  3  htbsp. 

23 

String  beam 

3  2  htbsp. 

13 

Coffee    .  .  . . 

.  1  cup 

Coffee    

.1  cup 

Coffee    

.  1  cup 

Butter     .  .  . 

.  1  ball 

119 

Cream   .  .  .  . 

.  1  tbsp. 

54 

Cream   .  .  .  . 

.  1  tbsp. 

54 

Butter 

.  1  ball 

119 

Butter     . .  . 

.  1  ball 

119 

Total  1100 

Thirteenth  day  following  sta 

rvation  day. 

Breakfast 

Dinner 

Supper 

amt. 

cal. 

amt. 

cal. 

amt. 

cal. 

Bacon    .... 

.  2  slices 

323 

Broth    

1  cup 

48 

Egg   

.  one 

83 

Tomato   .  .  . 

.  i  small 

23 

Roast 

Spinach     .  . 

.  2  htbsp. 

57 

String  beans 

3  2  tbsp. 

13 

chicken    .  . 

1  slice 

90 

Cabbage    . . 

. 3  htbsp. 

5 

Tea    

.  1  cup 

Cauliflower 

.2  htbsp. 

8 

Celerv 

6  small 

Cream   .... 

.  1  tbsp. 

54 

Asparagus    , 

,  2  htbsp. 

23 

stalks 

16 

Butter     .  .  . 

.  1  ball 

119 

Milk    

,  small 

Coffee    

.  1  cup 

glass 

80 

Cream   .... 

.  1  tbsp. 

54 

Butter     

1  ball 

119 

Total  111 

5 

DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 


593 


Fourteenth  day  following  starvation  day. 


Breakfast 

Dinner 

Supper 

amt. 

cal. 

amt. 

cal. 

amt. 

cal. 

Egg    

.  .  one 

83 

Chicken 

Cold  ham 

. .  one  slice 

140 

Tomato 

one  small 

broth  . . . 

.  1  cup 

42 

Cabbage    . 

.  .  3  htbsp. 

5 

size 

46 

Squab    .... 

.one 

300 

Lettuce   .  . 

. . 2  or  3 

Coffee    .... 

.  .  1  cup 

Celery   .... 

.3  small 

leaves 

4 

Cream   . .  . 

.  .  1  tbsp. 

54 

stalks 

8 

Butter     .  .  , 

.  .  1  ball 

119 

Butter     .  .  , 

.  .Iball 

119 

Boiled  onion.one  onion   42 

Tea    

.  .  1  cup 

Tea     

.  1  cup 

Cream   .... 

.  2  tbsp. 

108 

Total  1055 

Fifteenth  day  folloicing  starvation  day. 

Breakfast 

Dinner 

Supper 

amt. 

cal. 

.    amt. 

cal. 

amt. 

cal. 

Egg    

.one 

83 

Broth    

. one  cup 

48 

Egg    

.  two 

166 

Bacon    .... 

.2  slices 

323 

Steak  tender 

Lettuce   . .  . 

.  2  leaves* 

4 

Peas     

.U  tbsp. 

90 

loin    small     serving 

286 

Bread    .  .  . . 

.  1  slice 

Tomato 

.i  small 

23 

Lettuce 

.  2  leaves 

4 

3  X  34" 

'    40 

Cream  .... 

.  1  tbsp. 

54 

Cabbage    . . 

.  3  htbsp. 

5 

Butter     .  .  . 

, .  1  ball 

119 

Coffee    

.1  cup 

Cream   .... 

.  2  balls 

108 

Tea    

.  1  cup 

Coffee    

.  1  cup 

Total  1360 

Sixteenth  day  foUou-ing  starvation  day. 

Breakfast 

Dinner 

Supper 

amt. 

cal. 

amt. 

cal. 

amt. 

cal. 

Bacon    .... 

.2  slices 

Chop,  lamb 

one 

Egg    

.  two 

166 

6"  long  323 

small 

367 

Spinach     .  . 

.2  htbsp. 

57 

Tomato   .  .  . 

.small 

46 

Cucumbers 

.8  thin 

Cabbage    . . 

.  3  htbsp. 

5 

String  beans  2  htbsp. 

23 

slices 

9 

Celery 

.  6  small 

Asparagus 

.2  htbsp. 

156 

Squash    .  .  . 

.2  htbsp. 

69 

stalks 

16 

Tea    

.  1  cup 

Lettuce   .  .  . 

.2  leaves 

4 

Coffee    

.  1  cup 

156 

Butter     .  .  . 

.  1  ball 

119 

Milk    

.small 
glass 

80 

Total  123 

5 

8: 

eventeenth  day  following  starvation  day. 

Breakfast 

Dinner 

Supper 

amt. 

cal. 

amt. 

cal. 

amt. 

cal. 

Egg    

.  one 

83 

Vegetable 

Cold  ham  . 

.slice 

93 

Parsnips  .  . 

.2  htbsp 

10 

soup  .  .  .  . 

.1   cup 

18 

Sprouts  .  . . 

.2  tbsp 

25 

Potato     .  .  . 

.one 

Roast 

Celerv   

.8  stalks 

19 

very 

chicken    . 

.1  slice 

90 

Tea  .' 

.1  cup 

156 

small 

Cauliflower 

.2  htbsp 

8 

Cream   .  . .  . 

. 1  tbsp 

54 

Milk    

.  small 

String  beans 

.2  htbsp 

13 

Butter 

.1  ball 

119 

glass 

80 

Tea 

.  1  cup 

156 

Bacon    .... 

.2  slices 

323 

Cream   .... 

.2  tbsp 

108 

Butter 

.1   ball 

119 

Total  1200 

Eighteenth   day  folloicing  starvation  day. 

Breakfast 

Dinner 

Supper 

amt. 

cal. 

amt. 

cal. 

amt. 

cal. 

Bacon    .... 

.2  slices 

323 

Chicken  .  .  . 

.small 

Egg    

.two 

166 

6"  Ion 

g 

portion 

109 

String  beans.2  htbsp 

13 

Egg    

.one 

83 

Cauliflower 

.2  htbsp 

8 

Turnips  .    . 

.2  htbsp 

6 

Asparagus 

.2  htbsp 

23 

Spinach  . . . 

.2  htbsp 

57 

Cream   .... 

.2  tbsp 

108 

Butter 

.1  ball 

119 

Butter 

.1   ball 

119 

Tea    

.  1  cup 

Cream   .... 

.2  tbsp 

108 

Cream   .... 

. 1  tbsp 

54 

Coffee    .... 

.  1  cup 

Tea    

.  1   cup 

Total  1319 

Nineteenth  day  folloi 

oing  starvation  day. 

Breakfast 

Dinner 

Supper 

amt. 

cal. 

amt. 

cal. 

amt. 

cal. 

Bacon    .... 

.2  slices 

323 

Beef  broth. 

.  1    cup 

32 

'Egg    

.two 

166 

6"  lonj 

Df 

3 

Round  steak. 

small 

185 

Asparagus 

.2  htbsp 

23 

Parsnips  .  . 

.2  htbsp 

10 

Celery    

6  stalks 

19 

Spinach     .  . 

.2  htbsp 

57 

Potato    .  .  . 

.1  htbsp 

56 

Tomata  .  .  .  . 

1  small 

46 

Bread    

.  1  slice 
3"x34" 

40 

38 


594 


DIET  IN  DISEASE 


Butter 1  ball       119 

Cream   2  tbsp       108 

Coffee    1  cup 


Cream 
Tea    .  . 


1  tbsp         54     Milk     small 

1  cup  glass       80 

Tea    1  cup 

Butter     1  ball        11!) 

Total  1400 


Twentieth  day  following  starvation  dan. 


Breakfast 

amt.  cal. 

Bacon    2  slices  323 

6"  long 

Egg    one  83 

Orange    ....  1   small  40 

Asparagus    .2  htbsp  19 

Tea    1  cup 

Butter     ...  .1  ball  110 

Cream   1  tbsp  54 


Dinner 

amt. 

Broth     

Lamb    chop. one 
Cabbage    ...  3  htbsp 
Tomato  ....  A  small 

Coffee    1  cup 

Cream   2  tbsp 

Butter     1  ball 


ii  upper 

cal.                                          amt.  cal. 

48      Egg    one  83 

367      String  beans.2  htbsp  13 

5     Cabbage  ....  3  htbsp  5 
23      Cucumber   .  .  8  thin 

slices  9 

108     Tea  .  ..  . 1  cup 

119      Cream   1  tbsp  54 

Butter     1  ball  119 


Total  13.50 


Ticenty-first  day  following  starvation  day. 


Breakfast 

amt.  cal. 

Egg    one  83 

Tomato   ....  1   small  46 

Cream 2  tbsp  108 

Coffee    I   cup 

Butter ball  119 


Dinner  Supper 

amt.  cal. 

Squab    one  300 

Spinach     ...2  htbsp  57 

String  beans.2  htbsp  13 

Lettuce   ....  2  leaves  4 

Boiled  onion.one  42 

Cream  1  tbsp  54 

Tea    I  cup 

Butter     1  ball  119 


amt. 


cal. 
S3 


Egg   one 

Salmon    ....  small 

serving  100 
Asparagus  .2  htbsp  23 
Celery   6  small 

stalks  19 
Milk    small 

glass       80 

Butter     1  ball        119 

Total  1350 


Breakfast 


Twenty-second  daAj  following  starvation  day. 
Dinner  Supper 


Eggs    two 

Parsnips  .  . .2  htbsp 

Bread    2  by  IJ 

Tea    1  cup 

Cream   1   tbsp 

Butter I  ball 


cal.  amt.  cal. 

166  Boiled  ham  .1  slice  290 

10  Cabbage    .  .  .3  htbsp  5 

20  String  beans.2  htbsp  23 

Milk 1  glass  140 

54     Butter 1  ball  119 

119     Spinach 2  htbsp  57 


amt.       cal. 
83 
150 
23 


Egg    one 

Cold  chicken.  1  slice 
Asparagus      2  htbsp 

Coffee    1  cup 

Cream 1  tbsp 

Butter 1   ball 


Twenty-third  day  folloiving  starvation  day. 


Breakfast 

amt.       cal. 
Orange    ....  1  small       40 

Bacon    1  slice  6"  161 

Egg    one  83 

Tomato   .  .  .  .i  small       23 
Bread 1  slice 

3x3JxA    80 

Tea    1  cup 

Cream   1  tbsp         54 

Butter 1   ball        119 


Dinner 

amt. 

Broth    1  cup 

Steak  round,     small 

portion  185 
Cucumber   .  .  8  thin 

slices  9 
2  htbsp  8 
1  cup 


Cauliflower 

Tea     

Cream 1  tbsp 

Butter 1  ball 


48 


Supper 

amt. 

Eggs    two 

String  beans.2  htbsp 
Asparagus  . . 2  htbsp 
Spinach     ...  2  htbsp 

Coffee    1  cup 

Cream   1  tbsp 

Butter r  ball 


54 
119 


cal. 

166 
13 
23 
57 

54 
119 


54 
119- 


Total  1400 


Twenty-fourth  day  following  starvation  day. 


Breakfast 

amt.       cal. 
Bacon    2  slices     323 

6"  long 
Asparagus  .  .2  htbsp      19 
Spinach  ... .2  htbsp      57 


Dinner 

amt.       cal. 

Broth 1  cup  48 

Chicken  ....  small 

portion  135 
Peas     li  tbsp       90 


Supper 


amt. 
two 
1   small 


Eggs    .  . 
Tomato 

Celery   

Cream   2  tbsp 


cal. 

166 
46 
19 

108 


DISEASES  ly  WHICH  DIET  IS  A  PKIMARY  FACTOR 


595 


Mill:     small 

glas 
Butter 1   ball 


Lettuce   ....  2  leaves       4     Tea    1  cup 

80     Butter 1  ball        119     Butter 1   ball        119 

119     Cream    1  tbsp         54 

Coflee    1  cup  Total  1500 

Tioenty-fifth  day  folloicing  starvation  day. 


Breakfast 

amt. 

Egg    one 

Bacon    2  slices 

Bread    3x3xi 

Caulitiower  .2  htbsp 

Milk    small 

glass 
Butter 1   ball 


Dinner 
cal.  amt.       cal. 

83     Broth 1  cup  48 

323     Tenderloin 
48         steak   ....  1  portion  280 
8     Lettuce   ... .2  leaves        4 
Boiled  onion. 1   onion       42 

SO     Butter 1   ball        119 

119     Cream    2  tbsp         54 

Coflee    1  cup 

Twenty-sixth  day  following  starvation  day 


Supper 

amt.  cal. 

Eggs     two  166 

String  beans.2  litbsp  13 

Tomato  .  .  .  one  46 

Tea    1  cup 

Butter 1  ball  119 

Cream   1  tbsp  54 

Total  1550 


Breakfast 

•imt.  cal. 

Egg    one  83 

Bacon    2  slices  328 

Tomato   ....  J  small  23 

Potato     1  htbsp  56 

Cream 1  tbsp  54 

Butter 1  ball  119 


Tea 


,  1    CUJ) 


Dinner 

amt.  cal. 

Broth    1  cup  48 

Squab    one  300 

Spinach     ...  2  htbsp  57 

Sprouts 2  htbsp  20 

Cucumbers    .8  thin 

slices  9 

Tea    1  cup 

Butter 1  ball  119 


Supper 

amt.  cal. 

Egg    one  83 

String  beans.2  htbsp  13 

Asparagus  .  .2  litbsp  23 

Cauliflower  .2  htbsp  8 

Coff'ee    1  cup 

Cream   1  tbsp  54 

Butter 1   ball  119 


Total   1500 


Twenty-seventh  day  following  starvation  day. 


Breakfast 


Orange    .  . 

Egg    

Asparagus 

Tea    

Cream   1  tbsp 

Butter 1  ball 


amt. 
1  small 
one 

.2  htbsp 
1  cup 


Dinner 
cal.  amt. 

40      Boiled  ham  .  1  slice 
83      Cabbage    ...  3  htbsp 

L3      Tomato 1   small 

Coffee    1  cup 

54     Cream 2  tbsp 

119      Butter 1  ball 


Supper 

cal.                                          amt.  cal. 

290     Bacon    2  slices  323 

5     Parsnips  ...2  htbsp  10 

46     Milk    small 

glass  80 

108     Butter 1  ball  119 

119     Spinach 2  htbsp  57 


Breakfast 


amt 


Egg    one 

Tomato   ....  J   small 

Bread    .3x3x  J 

Cofl'ee    1  cup 

Cream   2  tbsp 

Butter 1  ball 


cal. 
83 
23 
48 

108 
119 


cal. 


90 

4 


80 
119 


Supper 
Egg 


Twenty-eighth  day  following  starvation  day 

Dinner 

amt 

Steak  small 

Tenderloin .     portion  256 

Peas 11  tbsp 

Lettuce   ....  2  leaves 

:\Iilk    small 

glass 
Butter 1  ball 


Total  1560 


Salmon small 

serving 
Asparagus  . . 2  htbsp 
String  beans.2  htbsp 

Tea 1  cup 

Cream   2  tbsp 

Butter 1  ball 


cal. 
83 

100 
23 
13 

108 
119 


Total   1400 


SUBSTITUTES  FOR  SUGAR 

Various  substances  are  used  in  place  of  sugar  to  sweeten  the  food 
and  drink  of  the  diabetic.  :\Iany  of  these  are  sold  under  trade  names, 
as  ''  Crijstallose  "  and  "  Diabetin."  Preparations  of  inulin,  of 
inosite,  of  mannite,  and  of  fruit-sugar  have  also  been  suggested  as 
being  less  injurious  than  cane-sugar. 

Glycerin  is  unsuitable. 

Saccharin  (benzovl-sulphonic-imid)  is  used  largely;  it  has  an  ex- 
ceedingly sweet  taste,  and  may  be  procured  in  tablets  that  are  equal  in 
sweetening  power  to  an  ordinary  lump  of  sugar.     If  taken  in  quan- 


596  DIET  IN  DISEASE 

titles  not  exceeding  five  grains  a  day,  it  is  harmless.     The  following 
is  a  much-quoted  formula  given  by  James  Stewart : 

Sodium  bicarbonate    gr.  xxx. 

Saccharin    gr.  xl. 

Mannite     5xijss. 

Make  100  pastilles.     One  will  sweeten  a  cup  of  coffee. 

Garantose  (sodium  benzoyl-sulphonic-imid — Hey  den)  is  a  much 
more  soluble  preparation  than  saccharin. 

Dulcin  (paraphenatolcarbamid — Hey  den)  is  in  common  use  in  Ger- 
many for  sweetening  the  food  and  drink  of  diabetics,  and  is  recom- 
mended by  many  of  the  highest  authorities.  In  the  small  quantities 
in  which  it  is  prescribed  it  is  harmless,  but  in  the  large  quantities  that 
have  been  given  experimentally  it  gives  rise  to  such  symptoms  as 
icterus,  etc.  More  than  half  a  gram  (8  grains)  should  not  be  given  in 
any  one  day.  It  may  be  procured  in  tablets  containing  0.025  gram 
each.  Each  of  these  has  the  sweetening  power  of  an  ordinarj'  lump 
of  sugar.  Some  patients  prefer  the  taste  of  dulcin  to  that  of  sac- 
charin, and  vice  versa. 

Saxin  is  a  coal-tar  product  used  to  sweeten  the  food  of  the  diabetic, 
and  is  said  to  be  six  hundred  times  sweeter  than  sugar;  many  pa- 
tients prefer  its  taste  to  that  of  the  other  preparations.  It  may  be 
obtained  in  tablet  form. 

Sugar-free  marmalades,  jellies,  and  jam  are  manufactured  by  Cal- 
lard  and  Co.  They  also  prepare  preserved  fruits  for  diabetics.  These 
fruits  are  said  to  contain  less  than  2  per  cent,  of  sugar. 

SUBSTITUTES  FOR  BREAD  i 

"Torrified"  Bread. — Thin  slices  of  bread  are  toasted  until  very 
dark  brown  or  almost  black.  It  is  supposed  that  the  starch  and  gluten 
are  partially  decomposed  by  the  heat.  This  will  almost  certainly  not 
be  eaten  to  excess  by  the  patient,  and  Williamson  states  that  this  is 
probably  its  only  advantage. 

Gluten  bread,  introduced  over  fifty  years  ago  by  Bouchardat,  has 
always  been  popular  in  France.  This  bread  is  made  from  gluten 
flour  from  which  the  starch  has  been  washed  out.  The  gluten  flours 
on  the  market  differ  verj^  much  in  the  amount  of  starch  which  they 
contain,  a  fact  that  can  be  illustrated  by  testing  with  an  iodin  solu- 
tion. 

Directions  for  making  gluten  bread  accompany  the  packages  of 
flour. 

Bran  bread,  made  from  bran  flour,  is  also  to  be  recommended.  The 
bran  must  be  ground  quite  fine,  or  it  wall  not  be  digested. 

Almond  cakes  and  cocoanut  cakes  are  of  considerable  value  as  bread 
substitutes.     Konig  gives  the  following  analysis  of  sweet  almonds: 

■  i  Recipes  for  these  will  be  found  in  the  Appendix. 


DISEASES  IN  ^VHICH  DIET  IS  A  PRIMARY  FACTOR  597 

Water 5.39  Carbohydrate     7.23 

Protein 24.18  Cellulose      ...  0.56 

Fat    53.68  Ash    2.96 

Aleuronat  is  a  vegetable  albumin  flour  made  by  Dr.  Hundhausen 
from  wheat.  It  is  a  light-yellowish  powder,  and  contains  from  80  to 
90  per  cent,  of  albumin  and  only  7  per  cent,  of  carbohydrate.  It  was 
recommended  in  diabetes  by  Ebstein,  who  suggests  that  it  be  mixed 
with  wheat  flour.  His  formula  contains  considerable  starch, — i.  e., 
about  one-half  the  amount  of  ordinary  bread;  and  most  patients 
prefer  to  have  half  the  quantity  of  wheat  bread  to  a  double  allowance 
of  aleuronat  bread. 

Buns  and  cakes  may  also  be  made  with  the  aleuronat  flour,  and  they 
are  very  palatable  if  made  with  the  addition  of  cocoanut  powder,  as 
suggested  by  Williamson.  Recipes  will  be  found  in  the  section  de- 
voted to  that  subject. 

Inulin  biscuits  have  been  suggested  by  Kiilz  and  others.  Their 
expense  is  a  great  objection  to  their  use.  Inulin  is  obtained  from 
the  roots  of  elecampane. 

Peanut  flour  has  also  been  used  with  success  in  making  various 
dishes  for  the  diabetic. 

A  large  number  of  diabetic  flours,  breads,  biscuit,  and  other  sugar 
and  starch-free  foods  are  prepared  by  Callard  and  Co.  of  London. 

Diabetic  Foods. — Numerous  diabetic  foods  are  on  the  market,  some 
of  which  contain  small  quantities  of  starch,  but  many  of  which  con- 
tain large  quantities,  that  are  sold  with  statements  which  are  not 
always  strictly  true. 

Many  of  the  so-called  diabetic  flours  are  made  from  wheat  flour  by 
washing  out  part  of  the  starch  and  then  drying.  Various  other 
cereals  and  the  seeds  of  various  legumes  are  also  used.  Almonds  and 
some  other  nuts,  and  also  casein  prepared  from  skimmed  milk  are 
frequently  used.  Care  should  be  taken  to  obtain  fresh  products,  as 
many  of  the  foods  are  packed  in  pasteboard  boxes,  may  be  infected 
with  moulds  or  insects,  and  also  change  somewhat  in  their  composition, 
due  to  the  evaporation  or  absorption  of  water. 

The  following  table  is  from  the  Report  of  the  Connecticut  Agricul- 
ture Station  Part  1,  1913.  We  are  indebted  to  the  Director  for  per- 
mission to  reprint  this  valuable  contribution.  The  percentages  of 
protein  were  obtained  by  using  the  factor  6.25  but  it  should  be  borne 
in  mind  that  for  gluten  and  wheat  flours  5.7  gives  nearer  the  exact 
figures.  In  the  products  with  a  very  high  protein  content  this  makes 
some  little  difference.  A  blank  space  means  that  the  carbohydrate 
was  not  determined  while  0  stands  for  its  absence. 


598 


DIET  IX  DISEASE 


Table  I. — Analyses 


P. 


1910      43 


1906 

8 

1912 

16 

1906 

8 

1913 

1906 

8 

1913 

1907 

10 

1906 

8 

1909 

19 

1912 

IG 

1913 

1906 

8 

1913 

1913 

1904 

7 

1906 

8 

1906 

8 

1909 

19 

1913 

1913 

1904 

7 

1906 

S 

1906 

8 

1906 

8 

1913 

1910 

34 

1913 

1913 

1909 

19 

1910 

34 

1908 

37 

1906 

8 

1913 

1911 

14 

1906 

8 

Manufacturer  and  Brand. 


Flours  and  Meals 

Acme  Mills  Co.,  Portland,  Ore.,  Acme  Diabetic  Flour   

Amthor  &  Co.,  Halle,  VVeizen-Protein   

Eerman  Barker,  Somerville,  Mass.,  Barker's  Gluten  Food  "A' 


"B" 

'•C" 


Bischof  &  Co.,  London,  Gluten  Flour 

Callard,  Stewart  &  Watt,  London,  Casoid  Flour 


Cereo  Co.,  Tappan,  N.  Y.,  Soy  Bean  Gruel  Flour  .  . .  . 

ic  ic  cc  a*'  a  a  a 

Farwell  &  Rhines,  Watertown,  IST.  Y.,  Cresco  Flour  . 
"  "  "  "        Gluten  Flour 


Farwell  &  Rhines,  Watertown,  N.  Y.,  Special  Diabetic  Food 

a  a  a  a  a  a  •; 

a  a  a  a  .t  u  .4 

"  "  "  "       Special  Dietetic  Food 


Gericke,  Potsdam,  Aleuronat   

Golden  Rod  Milling  Co.,  Portland  Ore.,  Acme  Special  Flour 
0.  B.  Oilman,  Boston,  Mass.,  Gluten  Flour  


Karl  Goldscheider,  Carlsbad,  Conalbin-Mehl  No.  1 


Gumpert,  Berlin,  Ultramebl 
Hazard's  Wheat  Protein   .  .  . 


Health  Food  Co.,  New  York,  Almond  Meal 


C  B  X  Cold  Blast  Flour,  25%  Protein 
Glutosac  Gluten   Flour   


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR  599 

OF  Diabetic  Foods. 


CJ 

M  •  0  C8 

_<u 

6 

s  . 

be  0} 

fcj.  CO 

^^ 

o 

Si 

ca 
o 

CS 

P. 
<o 

p. 
o 

-3 

a 

3 

o 

u 

P. 

o 

V 
C8 

J5 

< 

«  • 

a 

'S  g 
003 

a*" 

.0 

01    ft 

0  0  J^ 

u 

J3 

Weight    supplyin 
same  amount  cai 
bohydrates  as  1 
gms.   wheat  bre 

0 

gms. 

cts. 

cts. 

% 

% 

% 

% 

% 

7c 

% 

gms. 

9.4 

1.1 

9.4 

0.8 

77.4 

1.9 

71.4 

7 

364 

8.6 

1.1 

84.1 

4.8 

1.4 

110 

368 

10.1 

0.2 

85.4 

0.0 

3.7 

0.6 

'*4.5 

143 

362 

363 

125 

ise 

7.4 

0.4 

86.9 

0.2 

4.6 

0.5 

Trace 

115 

370 

10.1 

0.2 

84.4 

0.0 

4.7 

O.G 

*6.0 

113 

362 

38i 

100 

119 

6.3 

0.4 

85.1 

0.4 

7.2 

0.0 

3.7 

74 

375 

9.7 

0.2 

82.5 

0.0 

6.8 

08 

*8.3 

78 

364 

385 

100 

iis 

5.7 

0.4 

84.1 

0.6 

8.6 

0.6 

34 

62 

377 

lO.l 

1.3 

79.8 

0.2 

5.0 

3.6 

106 

372 

907 

150 

75 

10.0 

2.5 

85.6 

1.4 

0.5 

0.0 

377+ 

353 

907 

150 

75 

10.3 

2.5 

82.5 

3.T 

1.6 

171+ 

357 

352 

50 

65 

4.9 

4.4 

45.7 

1.9 

22,6 

20.5 

"  0.6 

23 

458 

467 

50 

49 

4.2 

4.2 

43.1 

2.2 

24.9 

21.4 

Trace 

21 

465 

12.7 

0.5 

11.1 

0.0 

74.8 

0.9 

7 

352 

454 

9 

"9 

12.7 

0.4 

18.1 

0.4 

67.4 

1.0 

57.2 

8 

351 

23-21 

50 

20.1 
9.4 

much 

1 

12.7 

0.4 

11.4 

0.3 

74.3 

0.9 

*71.5 

'1 

351 

13.3 

0.5 

10.8 

0.1 

74.3 

1.0 

72.0 

7 

349 

10.7 

0.5 

12.0 

76.T 

0.5 

7+ 

358 

2330 

lis 

22 

8.3 

0.6 

43.1 

0.2 

46.6 

1.2 

38.1 

11 

370 

509 

15 

13 

8.6 

0.5 

46.3 
13.5 

0.6 

42.9 

1.1 

32.8 
much 

12 

1 

367 

12.0 

1.9 

14.3 

1.4 

67.4 

'3,0 

*58.3 

8 

354 

10.3 

1.6 

14.2 

1.1 

70.0 

2.8 

*62.1 

8 

362 

12.4 

1.3 

12.8 

0.6 

70.3 

2.6 

8 

358 

445 

10 

10 

9.6 

1.8 

27.5 

1.7 

56.6 

2.8 

40.0 

9 

362 

9.3 

0.9 

83.4 

3.T^ 

3.3 

171+ 

376 

10.0 

0.7 

15.8 

0.7 

71.4 

1.4 

57.9 

7 

361 

454 

11 

11 

,  8.7 

1.0 

47.3 

0.6 

40.4 

2.0 

31.4 

13 

369 

9.4 

0.5 

10.9 

78.8 

0.4 

7+ 

362 

6.6 

2.9 

36.5 

9.4 

44.6 

.56+ 

585 

7.0 

0.6 

41.8 

0.3 

49.1 

1.2 

11 

374 

8.5 

6.4 

50.6 

2.9 

16.0 

15.6 

*7.2 

33 

407 

469 

100 

97 

7.9 

6.3 

50.3 

2.8 

17.9 

14.8 

Trace 

30 

406 

2350 

75 

15 

8.7 

0.5 

10.1 

0.2 

79.6 

0.9 

68.9 

7 

367 

10.1 

1.1 

34.1 

I.O 

52.1 

1.6 

*49.3 

10 

359 

*  Determined  by  the  diastase  method,  without  previous  washing  with  water, 
and  calculated  as  starch. 


600 


DIET  IN  DISEASE 


Table  I. — Analyse^: 


C3^ 

p 

1909 

19 

1911 

3s 

1913 

1913 

1906 

S 

1913 

1913 

1906 

8 

1913 

1892- 

6  30 

1892- 

6  30 

1906 

8 

1906 

8 

1913 

1913 

1913 

1913 

1913 

1913 

1906 

8 

1906 

8 

1906 

8 

1911 

14 

1911 

38 

1904 

39 

1909 

19 

1912 

16 

1906 

8 

1906 

8 

1909 

19 

1912 

16 

1913 

1909 

19 

1909 

19 

1912 

16 

1913 

1913 

Manufacturer  and  Brani 


Flours  a>d  Meals.     (cont.J 


Bealth  Food  Co.,  New  York,  Glutosac  Gluten  Flour 


Health  Food  Co.,  Xew  York,  Pronireu  (Gluten  Griddle  Cake  Flour) 
"  •'  •'  Protosac  Gluten  Flour 


R.  Hundhausen,  Hamm,  Aleuronat   (pure)    

"  "  "  (less  pure)    .  .  .  . 

Jireh  Diabetic  Food  Co.,  New  York,  Diabetic  Flour 


Protosoy  Soy  Flour   

Pure  Washed  Gluten  Flour 


Flour      

Patent  Barley    

"        Cotton  Seed  Flour 
"        Lentils  Flour   

Protein  Flour 

Soja  Bean  Flour   

Wheat  and  Barley  Flour   . 


Johnson  Educator  Food  Co.,  Boston,  Mass.,  Educator  Standard  Gluten 

Flour 
Johnson  Educator  Food  Co.,  Boston,  Mass.,  Educator  Standard  Gluten 

Flour 
Tohnson  Educator  Food  Co.,  Boston,  Mass.,  Educator  Standard  Gluten 

Flour 


The  Kellogg  Food  Co.,  Battle  Creek,  Mich.,  20%  Gluten  Meal 


rhe  Kellogg  Food  Co.,  Battle  Creek,  Mich  ,  40%  Gluten  Flour 

a  it  ii  •  (i  ii  it 


80%  Gluten 


"    Self-Raising 


Eugene  Loeb,  New  York,  Gluten  Cracker  Meal   .  . 
"  "  "  Imported  Gluten  Flour 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR  601 

OF  Diabetic  Foods. — Continued. 


s 

"c 

d 

55 

■a   . 
S5 

es 

u 

eS 

s 

a. 
1 

•0 

s 
0 

A 
u 

c. 

0 

0 

< 

10 

i 

c 
0 

u 

u 

k 
0  0 

u 

J3 

Weight     supplying 
same  amount  car- 
bohydrates as  10 
gms.   wheat  bread. 

C 
0 

^a 

n  » 

gms. 

cts. 

cts. 

% 

% 

% 

% 

% 

% 

% 

gms. 

8.0 

1.1 

35.3 

55.0^ 

0.6 

10+ 

367 

8.7 

36.6 

V 

'847 

35 

i9 

8.2 

1.4 

39.9 

0.7 

47.5 

'2.3 

'36.9 

11 

370 

855 

30 

16 

8.8 

4.9 

37.3 

0.5 

47.3 

1.2 

37.7 

11 

349 

10.6 

0.7 

36.6 

0.3 

50.9 

0.9 

*50.0 

10 

358 

839 

40 

22 

8.0 

0.9 

42.7 

0.3 

46.4 

1.7 

36.3 

11 

372 

500 

50 

45 

3.0 

5.0 

42.3 

5.4 

24.5 

19.8 

Trace 

21 

446 

6.2 

0.8 

62.4 

0.2 

29.5 

0.9 

•27.5 

18 

376 

'889 

50 

'26 

6.1 

0.5 

.80.3 

0.4 

11.1 

1.6 

7.0 

48 

380 

8.5 

0.9 

86.1 

.. 

4.0 

0.5 

133 

365 

9.1 

1.2 

77.7 

0.2 

10.6 

1.2 

50 

364 

9.3 

1.3 

14.3 

1.0 

71.9 

2.2 

*66.6 

7 

365 

11.0 

1.3 

12.1 

1.1 

72.7 

1.8 

7 

355 

li44 

30 

"i2 

7.6 

1.4 

14.4 

1.4 

72.9 

2.3 

60.9 

7 

370 

475 

25 

24 

5.0 

1.1 

11.4 

0.7 

80.2 

1.6 

67.8 

7 

381 

495 

20 

18 

7.4 

5.5 

49.1 

4.0 

21.3 

12.7 

6.0 

25 

396 

469 

25 

24 

5.9 

2.5 

27.3 

3.3 

59.8 

1.2 

42.6 

9 

359 

1124 

50 

20 

7.3 

1.7 

31.4 

0.9 

56.7 

2.0 

48.5 

9 

370 

457 

30 

30 

4.4 

4.6 

42.3 

4.7 

25.8 

18.2 

0.0 

21 

435 

9.7 

1.5 

11.8 

1.6 

73.5 

1.9 

*66.2 

7 

358 

9.5 

1.6 

11.3 

1.4 

74.4 

1.8 

7 

359 

11.3 

1.0 

26.4 

0.4 

59.2 

1.7 

•56.8 

9 

358 

1358 

38 

"is 

7.3 
8.8 

0.8 

40.1 
40.1 

0.2 

50.2 

1.4 

40.9 

11 

374 

10.5 

1.0 

15.8 

0.4 

71.7 

0.6 

"57.4 

'7 

355 

8.9 

1.1 

21.0 

esT'     • 

0.8 

8+ 

364 

428 

'25 

'26 

9.8 

1.4 

27.5 

0.1 

60.7 

0.5 

'49.6 

8 

357 

10.5 

0.5 

40.3 

0.2 

47.3 

1.2 

•46.9 

11 

361 

8.5 

1.4 

38.4 

0.1 

50.4 

1.2 

*50.0 

11 

366 

7.9 

1.2 

39.0 

50^P 

1.8 

11+ 

373 

320 

50 

'71 

9.7 

1.4 

47.0 

0.2 

40.8 

0.9 

31.9 

13 

350 

414 

50 

55 

8.0 

1.2 

43.7 

0.2 

46.0 

0.9 

40.5 

11 

367 

8.8 

1.3 

38.7 

50.2^ 

1.0 

11  + 

365 

7.2 

0.6 

78.8 

12.5 

0.9 

42+ 

373 

425 

'eo 

"64 

9.1 

0.6 

81.3 

0.2 

7.9 

0.9 

"  '6.2 

67 

365 

134 

15 

51 

9.7 

1.0 

27.8 

0.? 

53.5 

7.7 

40.2 

10 

394 

40 

9.2 

1.4 

76.3 

0.4 

11.8 

0.9 

4.4 

45 

361 

•  Determined   by  the  diastase  method,  without  previous  washing  with  water, 
and  calculated  as  starch. 


602 


DIET  IN  DISEASE 


Table  I. — Analyses 


1913 
1913 
1913 
1913 
1913 

1906  8 
1906  8 
1913 
1906  8 
1913 

1901-2  44 
1913 
1913 
1904  7 

1911   14 

1902-3  2 
1904  39 
1906  8 
1901  2 
1906  8 

1906  8 

1901  36 
1911  38 
1911   38 

1913 
1895  1 

1902-3  2 
1913 

1913 
1913 
1913 

1911  38 
1911      38 

1913 
1913 


1912    17 
1900-1    2- 


Eugene  Loeb,  New  York,  Pure  Gluten  Flour 

Whole  Wheat  Flour 

E.  Loeb  &  Co.,  New  York,  Gluten  Flour 

Thos.  Martindale  &  Co.,  Philadelphia,  Special  Gluten  Flour 
Mayflower  Mills,  Fort  Wayne,  Ind.,  Bond's  Diabetic  Flour  . 


Theo.  Metcalf  Co.,  Boston,  Mass.,  Soja  Bean  Meal,     5.5%  Starch. 

7.6%        "      . 

"  '•         "         "        18.0%        "      . 

Vegetable  Gluten,  20.0%       "      . 

8.1%        •'      . 

H.    Niemoller,    Giitersloh,    Roborat    

Pieser-Livingston  Co.,  Chicago,  Gluten  Flour 


Pure  Gluten  Food  Co.,  New  York,  Gum  Gluten  Flour 

Pure  Gluten  Food  Co.,  New  York,  Gum  Gluten  Ground  . . . . 

(  <(  <(  <<  <f  a  <( 

(  <c  ((  (I  <>  i(  <l 

"       Self -Raising' 


Pure  Gluten  Food  Co.,  New  York,  Hoyt's  Gum  Gluten  . 

Plain  Gluten  Flour 
"  Pure  Gluten  Flour   . 


Rademann's  Nahrmittelfabrik,  Frankfurt,  Diabetiker  Mehl 
Ralston  Health  Food  Co.,  Gluten  Flour 


Sprague,  Warner  &  Co.,  Chicago,  Richelieu  Gluten  Flour  . 

G.  Van  Abbott  &  Sons,  London,  Almond  Flour 

Gluten  Flour   

"  "  "         Gluten   Semola    

Vilson  Bros.,  Rochester,  N.  Y.,  Gluten  Flour,  ^  Standard 


"       Self -Raising,  ^  Standard. 


Protein  Preparations. 
The  Bauer  Chemical  Co.,  Berlin,  Sanatogen  . .  . 
Eiweiss-Extrakt  Co.,  Altona,  Germany,  Soson   . 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 


603 


OF  Diabetic  Foods. — Continued. 


S 

be 

in 

M 

c  5  —  0- 

'Ut 

OS 

'^ 

OJ 

N 

X 

'^  CJ     ^ 

o 

o 

e 
s 
o 

to" 

s 

W 

"a  If. 

s 

SCO) 

p. 

^ 

a 

S   o   (h    V 

6 

n 
1^ 

(D 
O 

1 

C! 
1 

is  c3 

CO 

^  s  t-  ^ 

'J  So  s 

^  M.Q  611 

«2 

«  p. 

ems. 

cts. 

cts. 

% 

% 

% 

% 

% 

% 

gms. 

423 

20 

21 

10.1 

0.6 

40.3 

0.3 

46.3 

2.4 

39.6 

11 

368 

424 

10 

11 

11.1 

1.1 

|14.6 

0.5 

70.5 

2.2 

54.6 

8 

360 

453 

50 

50 

9.8 

0.5 

43.9 

0.3 

44.4 

1.1 

39.8 

12 

363 

900 

30 

15 

8.2 

0.6 

40.3 

0.3 

49.1 

1.5 

41.4 

11 

371 

1445 

30 

9 

9.4 

0.6 

40.2 

0.2 

48.3 

1.3 

40.6 

11 

366 

7.8 

4.4 

39.9 
36.8 

3.9 

24.9 

19.1 

*9.0 

21 

9 

431 

453 

50 

50 

6.5 

4.1 

41.0 

3.4 

25.0 

20.0 

21 

444 

7.9 

0.7 

61.4 

0.3 

28.1 

1.6 

*26.8 

19 

372 

453 

50 

50 

7.6 

0.5 

80.4 

0.2 

9.8 

1.5 

5.9 

54 

374 

9.5 

1.4 

82.3 

0.2 

2.9 

3.7 

183 

374 

8.5 

0.6 

43.3 

0.1 

46.2 

1.3 

38.4 

11 

370 

1358 

43 

14 

8.7 

0.6 

41.8 
.54.3 

0.2 

47.3 

1.4 

36.5 

11 

9 

369 

464 

15 

15 

8.1 

1.0 

38.3 

0.2 

50.8 

1.6 

42.4 

10 

371 

11.9 

0.9 

26.8 

59^ 

*" » 

0 

1.4 

9+ 

356 

.  .  . 

10.6 

0.8 

44.1 

0.4 

42.8 

1.3 

30.0 

12 

3.59 

6.9 

1.0 

50.1 

0.5 

39.6 

1.!) 

*38.6 

13 

376 

9.8 

3.8 

31.5 

0.3 

53.2 

1.4 

10 

351 

10.8 

4.5 

37.9 

0.5 

45.3 

1.0 

*42.9 

12 

342 

11.2 

1.0 

31.8 

0.3 

54.1 

1.6 

*52.0 

10 

358 

9.9 

0.6 

53.6 
37.9 

0.2 

34.5 

1.2 

15 
•? 

363 

9.1 

39.3 

46.8 

7 

246 

20 

37 

9.6 

0.8 

37.9 

0.2 

50.7 

0.8 

11 

362 

12.8 

0.6 

15.0 

0.6 

69.0 

2.0 

8 

354 

11.9 

0.9 

15.8 

70 

9 

0.5 

31.6 

7+ 

351 

1357 

69 

23 

8.7 

0.5 

49.7 

0.2 

39.7 

1.2 

0.0 

13 

368 

480 

48 

45 

4.0 

3.0 

24.6 

1.9 

7.9 

58.6 

12.4 

67 

657 

902 

144 

72 

10.2 

0.8 

75.1 

0.4 

12.6 

0.9 

28.2 

42 

359 

60 

10.1 
11.1 

9.7 

2.8 

51.4 
19.9 
19.5 

0.4 

32.4 

2.9 

54.6 

16 

361 

io 

11.0 

1.2 

20.8 

0.3 

64.6 

2.i 

51.8 

8 

361 

1296 

25 

9 

12.2 

4.6 

17.4 

0.3 

63.5 

2.0 

8 

342 

200 

190 

431 

10.0 

5.6 

80.1 

^ 

2 

0.1 

126+ 

338 

6.4 

1.0 

91.2 

1 

1 

0.3 

482+ 

372 

*  Determined  by  the  diastase  method, 
and  calculated  as  starch. 


without  previous  washing  with  water, 


604 


DIET  ly  DISEASE 


Table  I. — Analyses 


1902 

29 

1913 

1899- 

1900 

r 

1901 

36 

1908 

11 

1909 

19 

1898- 

i  •:>7 

1900 

r' 

1901 

36 

1913 

1892 

26 

1892 

26 

23 

1910 

20 

1910 

20 

1910 

20 

1910 

20 

1910 

20 

1910 

34 

1910 

34 

1910 

34 

1910 

34 

1910 

34 

1910 

34 

1910 

34 

1910 

34 

1910 

34 

1910 

34 

1910 

34 

1892 

22 

1906 

8 

Manufacturer  and  Brand. 


Pkotein  Preparations,     (cant. J 

Krecke  &  Co.,  Salzuflen,  Energin 

Menley  &  James,  New  York,  Glidine 

Plasmon  Co.,  London,  Plasmon,    (average  9  analyses)    

a  it  a 

«  ((  <( 

Troponwerke,  Miilheim,  Tropon,   (average  of  many  analyses)    

Soft  Breads. 

Ferguson  Bakery,  Boston,  Mass.,  Gluten  Bread  

Frank  &  Co.,  Bockenheun,  Protein-Roggenbrot   

"  "  Protein-Weizenbrot     

Fritz,   Vienna,   Aleuronatbrot    

Kleberbrot,  Schwarz     

Litonbrot     , 

Fromm  &  Co.,  Dresden,  Conglutinbrot  

Litonbrot     .... 

Gericke,  Potsdam,  Doppel-Porterbrot   

Dreifach-Porterbrot     ...    

Einfach-Porterbrot    

Sifarbrot , 

Karl  Goldscheider,  Carlsbad,  Sinamylbrot   

Gumpert,  Berlin,  Diabetiker-Doppel-Schwarzbrot   . 

Weissbrot     .  . 

Einfach-Schwarzbrot 

Weissbrot     .  . 
Ultrarbot    

F.  Giinther,  Frankfurt,  Kleberbrot    

Bealth  Food  Co.,  New  York,  Glutosac  Bread 


DISEASES  IN  WHICH  DIET  IS  A   FKIMARY  FACTOR  605 

OF  Diabetic  Foods. — Continued. 


No.   of    Pieces. 
Net  weight  of 

OS 
C3 

c. 
o 

c 
c 

a 
c 

I. 

< 

1.-5 

i 

a 
'3 
o 

u 

u 

£ 

a 

a 
p  o 

o 

.s 

Starch. 

Weight    supplying 
same  amount  car- 
bohydrates as  10 
gms.   wheat  bread 

1)  O 

c3  p. 

gn 

IS. 

els. 

cts 

% 
9.1 

% 

1.0 

% 

83.8 

% 
0.3 

% 
1.3 

4.5 

% 

gms. 
408 

381 

'.'.        2i 

U 

150      5 

>4( 

)        5.7 
11.9 

0.9 
7.5 

91.4 
70.2 

0.2 

1.0 

0.8 
0.7 

o' 

530 

55+ 

,377 

'9^^7  ' 

326 

8.5 

7.4 

75.0 

8.9~ 

0.2 

60+ 

337 

1'- 

>8 

35       ] 

■24 

I       12.4 

7.7 

70.3 

9.2 

0.4 

58+ 

322 

10.9 
9.3 

7.6 
1.2 

78.7 
86.6 

0.0 

2.7 
0.2 

196+ 

339 

2.7 

359 

9.2 

0.8 

88.5 

1.2 

0.3 

442  + 

362 

'i      4- 

'6 

20 

U 

)      37.2 

1.7 

24.2 

0.2 

33.6 

3.1 

25.2 

16 

259 

32.0 

2.8 

23.7 

2.3 

33.0 

6.2 

16 

283 

31.9 

2.7 

23.4 

2.2 

33.5 

6.3 

16 

284 

35.5 

1.3 

15.6 

0.2 

46.6 

0.8 

11 

256 

'l    'l 

4 

21.5 

48.6 

11 

1        2f 

>9 

38.6 

15.4 

34 

1        2' 

■3 

18.3 

47.3 

11 

1        3i 

55 

35.8 

14.3 

37 

1        1' 

t5 

38.6 

26.9 

35.1 

15 

38.9 

1.1 

21.9 

36.7^ 

1.5 

14+ 

248 

35.1 

1.3 

30.7 

0.4  1  26.0 

6.5 

19.8 

20 

285 

30.5 

1.6 

17.8 

48.2 

1.8 

11  + 

280 

39.6 

2.2 

37.3 

0.6 

15.0 

5.3 

12.3 

35 

257 

39.1 

3.5 

28.2 

4.4 

20.2 

4.6 

17.3 

26 

235 

25.6 
27.9 

1.6 
1.6 

18.5 
15.9 

0.5 

42.0 

11.8 
12.7 

39.4 

13 
13+ 

348 

42.0^ 

346 

23.7 

2.3 

18.8 

0.4  1  39.4 

15.4 

36.8 

13 

371 

30.1 

1.4 

15.6 

49.5 

3.4 

11  + 

291 

29.4 

1.5 

16.2 

46.4 

6.5 

11  + 

309 

27.9 

3.1 

28.2 

0.8 

7.8 

32.2 

6.8 

68 

434 

33.7 

2.4 

17.2 

0.7 

45.5 

0.5 

12 

255 

31.5 

1.9 

27.4 

0.4 

36.1 

2.7 

*29.9 

15 

278 

*  Determined  by  the  diastase  method,  without  previous  washing  with  water,  and 
calculated  as  starch. 


606 


DIET  IN  DISEASE 


Table  I. — Analyses 


1906 

s 

1892- 

6  -1 

1906 

8 

1913 

1913 

1910 

34 

1910 

20 

1910 

34 

1910 

34 

1910 

20 

1910 

34 

1910 

20 

1892 

26 

1910 

34 

1894 

22 

1910 

20 

1910 

20 

1899 

33 

1907 

10 

1907 

10 

1910 

13 

1912 

16 

1909 

19 

1909 

19 

1906 

s 

1909 

19 

1913 

1908 

12 

1909 

19 

1908 

12 

1909 

19 

1908 

12 

1909 

19 

1909 

19 

Soft  Breads,     (cont.j 

Health  Food  Co.,  New  York,  Protosac  Bread   

R.  Hundliausen,  Hamni,  Aleuronatbrot,  low  gluten 

Jireh  Diabetic  Food  Co.,  New  York,  Whole  Wheat  Bread 

Eugene  Loeb,  New  York,  P.  &  L.  Genuine  Gluten  Bread 


( not   fresh ) 


Rademann's  Nahrmittelfabrik,  Frankfurt,  Diabetiker-Grahambrot   .... 

"         Schwarzbrot  (dry) 


Weissbrot   ( dry ) 


"D.-K"  Brot    (dry) 

Erdnuss-Brot 

Litonbrot    


Schelte,  Miinster,  Aleuronatbrot   

Seidl,  Miinehen,  Aleuronatbrot 

"  "  Kleberbrot    

Troponwerke,  Miilheim,  Tropon-Brot   

Hard  Bread  and  Bakery  Products. 


Bisehof  &  Co.,  London,  Diabetic  Gluten  Bread  

"            "             "        Essentiel  Bread  for  Super  Alimentation 
Brusson  Jeune,  Villemur,  France,  Gluten  Bread 


C'allard,  Stewart  &  Watt,  London,  Almond  Biscuit,  Plain 
*'  "  "  "  Almond  Shortbreads    . 

"  "  "  Casoid  Biscuits,  No.  1 

it  <l  (•  (C  II  a  a 

No.  2 


Callard,  Stewart  &  Watt,  London,  Casoid  Biscuits  No.  3 
"  "  "  "  "       Dinner  Rolls    . 


Lunch  Biscuit 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR  607 

OF  Diabetic  Foods. — Continued. 


o 

■3 
a 
3 

0 

ilying 
t  ear- 
as   10 
bread. 

S 
0 

"3  m 

£ 

tCo 

P, 
t-, 

0 

^ 

2 

0  ai  s. 

til 

■5  ** 

0 

fl 

Oi 

0,  0 

'c 

O 

■sl 

0 

0 

C9 

< 

0 

u 

Cm 

si 

.a 

00 

§  I" 
«p. 

gms. 

cts. 

cts. 

% 

% 

7c 

% 

% 

7c 

% 

gms. 

27.3 

1.4 

32.5 

0.2 

37.0 

1.6 

*33.1 

14 

292 

39.6 

1.6 

17.3 

0.6 

40.6 

0.3 

13 

234 

39.2 

1.8 

9.4 

0.6 

48.6 

0.4 

*43.8 

11 

236 

10 

21.8 

2.5 

12.4 

0.6 

62.0 

0.7 

449 

9 

304 

32i 

io 

14 

31.4 

1.6 

10:4 

0.3 

53.7 

2.6 

44.2 

10 

280 

31.7 

1.8 

9.8 

2.1 

49.4 

5.1 

45.6 

11 

283 

i96 

37.8 

33.3 

16 

29.1 

1.9 

14.5 

1.4 

50.5 

'2.5 

45.8 

10 

283 

33.6 

1.9 

14.9 

4f.r 

1.9 

11  + 

267 

128 

43.4 

28.1 

19 

33.8 

1.9 

23.3 

0.4 

40.1 

0.5 

37.0 

13 

258 

2i7 

12.3 

58.9 

9 

24.6 

3.8 

33.6 

5.5 

19.7 

12.8 

27 

328 

42.6 

2.4 

30.2 

0.7 

21.6 

2.5 

17.5 

25 

230 

38.8 

1.3 

18.3 

0.9 

40.1 

0.6 

13 

239 

"i64 

28.0 

21.9 

47.3 

0.3 

11 

280 

138 

24.2 
42.1 

18.6 
19.5 

54.4 

0.7 

10 

1 

298 

7.4 

4.7 

73.1 

0.0 

14.3 

0.5 

37 

354 

7.3 

4.8 

26.6 

0.1 

59.6 

1.6 

9 

359 

"36 

10 

150 

7.8 

1.1 

32.1 

0.2 

57.0 

1.8 

9 

373 

34 

10 

133 

12.7 

0.8 

37.3 

0.3 

47.1 

1.8 

49.8 

11 

354 

3.7 

3.2 

28.3 

36.r 

28.0 

40.1 

14+ 

512 

4.2 

3.5 

19.5 

20.7 

52.1 

26+ 

630 

7.8 

3.9 

63.0 

"i^^oT 

17.3 

*8.1 

66+ 

444 

7.2 

2.5 

64.8 

8.7 

16.S 

61  + 

445 

54 

226 

150 

300 

4.8 

3.4 

66.8 
58.1 

0.4   5.8 

18.8 

'  4.0 
0.0 

91 

460 

150 

7.5 

3.6 

57.8 
54.7 

5.6 

25.5 

Trace 

95+ 

9 

483 

150 

7.9 

5.0 

54.3 

80.8 

7.8 

25.0 

V3..3 

68+ 
9 

473 

150 

7  0 

1.8 

78.0 

2.1 

11.1 

252+ 

420 

1  ■■•• 

4.2 

3.8 

25.5 

21 

.6 

44.9 

25+ 

593 

*  Determined  by  the  diastase  method,  without  previous  washing  with  water,  and 
calrulated  as  starch. 

t  By  direct  acid  hydrolysis,  calculated  as  starch. 


€08 


DIET  ly  DISEASE 


Table  I. — Analyses 


1909  i» 

1909  19 

1909  19 

1909  19 
1913 

1909  19 

1909  19 

1913 
1913 
1913 
1913 
1913 
1913 

1913 

1892  26 

1910  20 
1910  20 
1913 
1313 
1913 
1913 
1910  20 
1913 

1913 

1913 

1913 

1913 

1910  20 

1913 

1910  20 

1910  34 

1910  20 

1910  20 

1910  20 

1910  20 

1910      34 


Manufacturer  and  Brand. 


Hard  Beeads  and  Bakeey  Peoducts.     (cont.J 
Callard,  Stewart  &  Watt,  London,  Casoid  Rusks 


Callard,  Stewart  &  Watt,  London,  Cocoanut  Biscuit  -(-  Saccharin 
"                 "             "        Ginger  Biscuit  -j-  Saccharin  .  . 
"  "  "  "        Kalari  Batons     


".       Biscuits    . 

"  "  '■  '•        Prolactic  Biscuit 

Charrasse  Biscuits  Croquettes  au  Gluten 

"  Biscottes  Lucullus   

"  Gluten  Exquis  Biscuits  aux  Amandes  . .  .  . 

Gluten  Fleur  de  Neige  Pain 

'■  Mignonettes  au  Gluten 

"  Pain  de  Gluten  


Tranches  Grillees  pour  Potage 


Frank  &  Co.,  Bockenheim,  Erdnuss-Kakes 

Fritz,  Vienna,  Braunes  Luftbrot  "B"   

'  "        Mandelbrot    

Fromm  &  Co.,  Dresden,  Almond-form  Wafers  with  Chocolate 

'■  "        Butterbrezeln     

"  "        Crackers   

"  "        Eierbiscuit     

"  "        Eiweissbrot 

"  "        Hazelnuss-Stangen    


Fromm  &  Co.,  Dresden,  Luft  Bread  . 
Makronen 
Salz-Stangen 
Stangenin     . 
Uni  Bread    . 


Gericke,  Potsdam,  Doppel-Porterzwieback 


Mandelbrot    .  .  . 
Porterbiskuits 
Porterzwieback 
Sifarbiskuits     . 


Groetzsch,  Frankfurt.  Diabetiker-Salsbrezeln 


DISEASES  IN   MfllCH  DIET  IS  A   riil.UARY  rAflOli  609 

OF  Diabetic  Foods. — Continued. 


M;  C  c: 

S 

cm 

i."^ 

vt 

==  rt-  - 

u 

« 

'O 

c* 

E4 

X 

•^  S  t 

0 

o 

5 
0 

0 

4) 

h 

u 

Oi 

Sat; 

■0 

a.  0 

o 

2 

p. 

0) 

C 

U 

^t3 

K-^ 

T. 

^  s  S  * 

s° 

c; 

"S 

v. 

a 

_^" 

0 

Z 

i  ? 

—  ? 

a 

.■lll^' 

z «- 

6 

12; 

0 

0 

0 
0 

^ 

< 

s 

S^ 

5:<  *" 

V. 

^g5S 

r^ 

gms. 

cts. 

cts. 

% 

7c 

% 

% 

% 

Cr 

% 

gms. 

5.4 

4.5 

37  0 

20.8 

323 

254- 

522 

2.6 

3.1 

16  6 

16.4 

613 

38+ 

684 

2.5 

3.7 

17.1 

TsT 

58  6 

29-^ 

668 

8.1 

4.4 

52.9 

09 

33  7 

(?) 
589 

519 

30 

*320 

150 

213 

4.5 

5.2 

43.2 

0.7  1  7.4 

39  0 

"0 

69 

553 

6.3 

3.7 

56.9 

1.7 

314 

312+ 

517 

63 

4.0 

42  9 

193" 

27.5 

27+ 

496 

97 

194 

135 

3i6 

7.3 

0.5 

34.3 

0  2 

52  3 

5  4 

30  6 

10 

395 

37 

530 

95 

81 

7.5 

1.8 

114 

0  2 

73  4 

57 

59.2 

7 

391 

24 

189 

150 

360 

5.3 

1.6 

18.1 

0.6 

50  6 

23  S 

25  5 

10 

489 

21 

146 

115 

357 

6.1 

2.3 

35.9 

04 

42  8 

125 

251 

12 

427 

47 

116 

90 

352 

8.2 

2.1 

40  1 

03 

43  6 

57 

27.3 

12 

386 

15 

481 

150 

141 

8.1 

2.1 

408 

02 

43.5 

5.3 

272 

12 

385 

81 

60 

336 

7.7 

2.3 

40.6 

03 

45.5 

36 

28.8 

12 

377 

COCQ 

6.4 

2.7 

32.2 

3.1 

36  5 

19.1 

15 

447 

i 

29 

42.6 

19  8 

27 

1 

45 

15.4 

23  1 

23 

54 

125 

65 

236 

2.6 

1.0 

4.8 

0.3 

62  3 

29  0 

"14  0 

8 

529 

18 

123 

35 

129 

6.3 

2.0 

123 

02 

62  7 

16.1 

43.1 

8 

449 

23 

91 

25 

125 

7.4 

3.4 

12.9 

0.2 

68.4 

7.7 

58.2 

8 

395 

8 

80 

35 

198 

7.7 

1.3 

18.8 

0.2 

60  6 

11.4 

37  5 

9 

420 

1 

13 

45.5 

37  5 

14 

15 

104 

'35 

i53 

5.2 

2.9 

13.4 

1.7 

60.8 

16.0 

00 

9 

441 

18 

263 

135 

233 

83 

8.9 

50.9 

0.2 

30.7 

1.0 

234 

17 

335 

24 

159 

65 

185 

6.0 

3  0 

14.1 

1.3 

56.2 

19.4 

00 

9 

456 

36 

156 

35 

102 

6.2 

3.6 

13  0 

0.4 

61.2 

15  6 

39.1 

9 

437 

42 

161 

35 

99 

6.6 

1.6 

14.0 

0.4 

64.4 

130 

51.6 

8 

431 

1 

12 

71.3 

86 

62 

18 

272 

135 

225 

8.1 

5.6 

71.7 

3.5 

9.4 

1.7 

'  2.9 

56 

340 

13 

72 

19.1 

41.0 

13 

4.9 

1.7 

34.2 

39.7 

19.5 

13+ 

471 

12 

"94 

16.2 

43.3 

12 

10 

31 

16.1 

63.0 

8 

13 

69 

26  4 

72  0 

7 

6 

64 

20.2 

35.3 

15 

14.0 

3.3 

36.3 

I7T 

293 

31  + 

477 

39 


610 


DIET  IN  DISEASE 


Table  I. — Analyses 


Manufacturer  and  Brand. 


1910  34 

1910  34 

1910  34 

1910  34 

1910  34 
1892  24 
1892  24 

1897  25 

1913 

1906  8 
1913 
1913 

1906  8 

1906  8 

1906  8 

1906  8 

1906  8 

1906  8 
1913 

1911  14 

1913 

1906  8 
1913 

1906  8 

1912  41 
1913 
1913 

1892-6    31 
1892-6    31 

1894  22 

1891  22 

1912  16 
1913 

1906  8 

1906  8 

1906  8 
1913 
1913 

1906  8 

1906  8 


Health  Food  Co.,  New  York,  Alpha  Best  Diabetic  Wafer 

Diabetic  Biscuit    


Health  Food  Co.,  Xew  York,  Glutosac  Butter  Wafers 

"  "  "        Rusks    

"  "  "        Wafers,  Plain 

"  "  "  "        Zwieback    

•'  "  "  No.  1  Proto  Puffs 


Hard  Breads  and  Bakery  Products,     (cont.) 

Gtroetzsch,  Frankfurt,  Diabetiker-Salzbrezeln   

"  "  Pfefferniisse   


Gumpert,  Berlin,  Diabetiker-Stangen  

"               *'        Doppel-Diabetiker-Zwieback 
P.  Giinther,  Frankfurt,  Aleuronat-Kakes 


Gluten  Nuggets 
Glutona    


Health  Food  Co.,  New  York,  No.  2  Proto  Puffs 


Protosac  Rusks   

Protosoy  Diabetic  Wafers 
Salvia  Sticks    


Heintz  Food  Co.,  Chicago,  Gluten  Biscuits 

ii  i(  it  a  tt 

"  "         Glutin  Biscuits 


R.  Hundhausen,  Hamm,  Aleuronatzwieback,  high  gluten 
"  "  "  low  gluten  . 

"  "         Aleuronat-Biskuits    

"  "  "         -Kakes    

Huntley  &  Palmer,  London,  Akoll  Biscuits 


Tireh  Diabetic  Food  Co.,  New  York,  Diabetic  Biscuits 


"          Rusks 
Dietetic  Biscuits 
Rusks     . 
Wheat  Nuts   


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 

OF  Diabetic  Foods. — Continued. 


611 


s 

o 

6 

S5 

o 

ea 

a 

P. 

u 

p. 

1 

0 

n 
o 

ft 

ft 
1 

J3 
< 

in 
to 

c 

0 
u 

S 

V 

a 

0  a 

.a 

Weight    supplying 
same  amount  car- 
bohydrates as   10 
gms.   wheat   bread 

oa 

c8  a 
0 

gms. 

cts. 

Cts. 

% 

5.3 

% 

1.6 

% 
34.5 

% 
0.3 

% 

22.9 

% 

35.4 

% 

gms. 
23 

548 

25.2 

2.8 

38.7 

9.3 

24.0 

57+ 

408 

•• 

15.2 

5.5 

2.6 
29 

39.2 
31.1 

0.7 

10.3 

32.0 
49.5 

51 

48+ 

486 

II.O 

614 

4.6 

25 

32.5 

0.8 

27.6 

32.1 

'27.1 

19 

529 

5.1 

0.8 

14.9 

0.4 

69.5 

9.3 

8 

421 

4.5 

1.6 

17.8 

0.9 

67.3 

7.9 

8 

412 

4.5 

1.5 

15.3 

, — ^ 
70 

F 

8.7 

8+ 

420 

17 

88 

50 

258 

4.9 

3.6 

66.1 

0.5 

11.3 

13.6 

Trace 

47 

432 

4.7 

3.1 

28.1 

0.3 

54.8 

9.0 

*51.I 

10 

413 

22 

32i 

25 

35 

89 

2.5 

25.0 

0.2 

54.2 

9.2 

46.5 

10 

400 

77 

360 

35 

44 

5.7 

2.8 

30.2 

0.2 

48.3 

12.8 

38.6 

11 

429 

4.8 

2.5 

22.1 

0.3 

58.5 

11.8 

*54.9 

9 

429 

4.7 

3.8 

27.6 

1.6 

49.4 

12.9 

*41.2 

11 

424 

4.5 

2.7 

36.5 

0.9 

51.6 

3.8 

*42.5 

10 

387 

6.1 

3.5 

29.4 

1.5 

49.9 

9.6 

*41.6 

11 

404 

7.6 

2.5 

32.5 

1.2 

49.3 

6.9 

*40.9 

11 

389 

8.6 

1.3 

75.9 

0.1 

13.1 

1.0 

*9.9 

40 

365 

io 

i41 

35 

ii3 

7  2 

2.7 

76.3 

0.2 

10.7 

2.9 

4.3 

50 

374 

161 

25 

71 

8.2 

1.8 

52.4 

0.2 

35.9 

1.5 

27.2 

15 

367 

'k 

119 

25 

95 

7.9 

2.5 

56.6 

0.2 

30.7 

2.1 

19.0 

17 

368 

59 

2.0 

40.9 

0.5 

48.7 

2.0 

*43.9 

11 

376 

43 

'ies 

40 

108 

3.9 

5.0 

43.1 

1.9 

21.2 

24  9 

4.7 

25 

481 

6.6 

7.5 

39.2 
13.1 

1.9 

24.0 

20.8 

*18.7 

22 

V 

440 

28 

'278 

25 

41 

6.4 

3.5 

12.8 

1.3 

57.7 

18.3 

21.4 

'  9 

447 

26 

259 

25 

44 

7.3 

3.0 

14.5 

1.0 

67.0 

7.2 

45.5 

8 

391 

8.5 

26 

66.2 

^ 

.7 

5.0 

30+ 

381 

65 

1.6 

22.9 

0.8 

59.6 

8.6 

9 

407 

[ . 

6.6 

4.7 

24.8 

0.5 

52  2 

11.2 

10 

409 

3.4 

1.1 

20  1 

1.2 

G4.8 

9.4 

S 

424 

"lis 

22 

'88 

9.3 

3.9 

53.2 

0.4 

6.3 

26.9 

Trace 

84 

480 

58 

302 

70 

105 

7.2 

34 

54.5 

0.7 

6.8 

27.4 

Trace 

78 

492 

6.3 

20 

14  8 

0.9 

72.3 

3.7 

*65.4 

7 

382 

8.9 

23 

13.1 

1.2 

70.6 

3.9 

7 

370 

8.7 

31 

14.6 

0.9 

67.7 

5.0 

8 

374 

42 

460 

30 

'36 

54 

20 

13  2 

1.2 

70.8 

7.4 

'496 

7 

403 

17 

231 

30 

59 

54 

1.9 

14.9 

1.1 

68.0 

S.7 

470 

8 

410 

76 

23 

19.0 

10 

54.5 

15  6 

*50,1 

10 

434 

6.0 

32 

21.0 

1.2 

46.3 

22.3 

11 

470 

*  Determined  liy  the  diastase  method,  without  previous  washing  with  water,  and 
calculated  as  starch. 


612 


DIET  IN  DISEASE 


Table  I. — Analyses 


1906  8 

1906  8 

1906  8 
1913 

1911  1* 
1906  8 
1906  8 
1906  8 

1899  35 

1912  ic 
1906  8 

1909  19 
1913 

1906  8 

1909  10 

1913 

1906  8 

1909  19 

1911  14 

1912  i« 
1913 
1912  i« 

1895  22 

1910  34 

1913 

1913 

1893  26 

1913 

1913 

1910  20 

1913 

1893  22 
1913 

1910  20 

1910  34 

1913 

1910  20 

1910  34 

1913 


The  Kellogg  Foo^  Co.,  Battle  Creek,  Mich.,  Avena-Gluten  Biscuit  . 

"       Potato  Gluten  Biscuit 


Pure  Gluten  Biscuit 


Manufacturer  and  Brand. 


Hard  Breads  axd  Bakery  Products.     (cont.J 

Johnson  Educator  Food  Co.,  Boston,  Almond  Biscuits 

Diabetic    Biscuits    . .  .  . 


Educator  Crackers,  Greseni  Gluten 

"         Gluten   Bread   Sticks .  . 
Gluten   Cookies    

"       Rusk,  Greseni  Gluten   .... 

"       Wafers     

Glutine,  Greseni  Gluten    


The  Kellogg  Food  Co.,  Battle  Creek,  Mich.,  Taro-Gluten  Biscuit 

"       40%  Gluten  Biscuil 


"   .  "       80%  Gluten  Biscuit 

Kirche,  Diisseldorf,  Aleuronat-Kakes   

Klopfer  Chemische  Fabrik,  Dresden,  Glidinebrot 

Eugene  Loeb,  New  York,  Gluten  Luft  Bread   

Pure  Gluten  Food  Co.,  New  York,  Gum  Gluten  Biscuit  Crisps  . . 
Rademann's  Nahrmittelfabrik,  Frankfurt,  Diabetiker-Biskuits  .  . 

a  i(  a  a  a 

Bretzel     '.'. 
Cakes   .  .  .  . 


Rademann's  Nahrmittelfabrik,  Frankfurt,  Diabetiker-Chokolade-Biskuits 

Dessert-Gebiick     .. 
Makronen    


Stangen 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 

OF  Diabetic  Foods. — Coniinued. 


613 


<u 

o 

©■ 

2 

to 
a 
,x 

0 

C8 

B. 

(H 

V 

p. 

0 

0 

■a 

3 

0 

u 
a 
0. 

0  . 
0 

J3 
< 

X 

Oh"' 

ca 

Weight    supplying 
same  amount  car- 
bohydrates  as   1 0 
gms.   wheat   bread. 

0 

0  " 

gms. 

cts. 

Cts. 

% 

5.3 

% 

2.1 

% 

29.0 

% 

0.5 

% 

54.3 

8.8 

% 

*50.0 

gms. 
10 

412 

5.9 

1.9 

25.3 

0.4 

59.0 

7.5 

*54.9 

9 

405 

6.2 

2.9 

23.0 

0.2 

63.1 

4.6 

*57.9 

8 

386 

12 

208 

30 

65 

8.4 

2.4 

35.9 

0.3 

45.8 

7.2 

37.5 

12 

392 

23 

259 

25 

44 

4.8 

2.7 

26.4 

0.3 

49.8 

16.0 

37.8 

11 

449 

6.2 

3.0 

22.1 

0.3 

68.1 

0.3 

*63.3 

8 

364 

6.9 

0.9 

30.3 

0.3 

61.2 

0.4 

*57.0 

9 

370 

6.4 

2.6 

21.9 

0.6 

67.7 

0.8 

*63.1 

8 

366 

10.2 

1.1 

13.8 

74^0^ 

0.9 

7-f- 

359 

349 

25 

33 

7.9 

2.1 

21.4 

0.4 

55.5 

12.7 

41.1 

10 

422 

8.2 

0.8 

80.0 

0.0 

10.6 

0.4 

*9.8 

50 

366 

7.6 

0.9 

75.6 

\^^ 

2.6 

404- 

379 

92 

'207 

30 

66 

8.8 

0.8 

41.5 

0.4 

48.0 

0.5 

39..3 

11 

363 

7.5 

1.0 

80.3 

0.2 

10.2 

0.8 

*9.1 

52 

369 

8.2 

1.1 

48.3 

.39.1^ 

3.3 

14+ 

379 

29 

'io6 

30 

128 

9.4 

0.7 

31.3 

0.4  1  57.7 

0.5 

48.2 

9 

361 

7.5 

1.6 

35.8 

0.1  1  54.0 

1.0 

*52.6 

10 

368 

7.5 

1.4 

36.4 

51.9 

2.8 

10+ 

378 

244 

40 

74 

8.0 

1.6 

43.3 

0.2 

45.7 

1.2 

35.3 

12 

367 

37 

89 

25 

129 

10.2 

0.5 

47.5 

0.2 

41.1 

0.5 

35.0 

13 

359 

24 

219 

50 

104 

7.2 

1.3 

37.2 

0.3 

53.2 

0.8 

45.0 

10 

369 

70 

190 

30 

72 

10.1 

2.1 

82.4 

0.1 

4.4 

0.9 

4.7 

118 

355 

.. 

5.0 

0.9 

17.0 

1.6 

61.8 

13.7 

32.8 

9 

439 

12.7 

2.3 

47.6 

0.3 

34.9 

2.2 

44.1 

15 

350 

3 

135 

25 

84 

7.3 

1.0 

27.9 

0.4 

54.2 

9.2 

39.3 

10 

411 

16 

106 

25 

107 

5.3 

1.7 

42.9 

0.9 

48.5 

0.7 

10.0 

U 

372 

2.9 

3.5 

44.1 

19.7 

29.8 

25.9 

27 

523 

i3 

105 

35 

151 

5.0 

1.1 

29.6 

0.2 

44.5 

19.6 

40.7 

12 

473 

16 

78 

25 

145 

6.8 

3.0 

31.4 

0.2 

50.1 

8.5 

11 

402 

10 

64 

12.6 

39.8 

39.1 

13 

19 

96 

'35 

165 

6.5 

3.6 

29.6 

0.2 

47.2 

13.5 

11.8 

11 

429 

1.8 

3.8 

44.9 

21.9 

27.6 

5.9 

24 

516 

17 

117 

65 

252 

4.3 

2.5 

22.2 

1.1 

27.5 

42.4 

19 

580 

10 

52 

12.3 

11.3 

S.S 

47 

4.5 

3.2 

22.3 

1.1 

20.9 

48.0 

3.0 

25 

605 

14 

"62 

45 

329 

4.0 

3.0 

23.2 

1.2 

20.6 

48.0 

26 

607 

10 

112 

22.7 

17.0 

31 

10.5 

2.1 

29.8 

24.6 

33.0 

22+ 

515 

13 

123 

'42 

155 

4.5 

3.6 

17.7 

0.5  1  29.5 

44.2 

21.4 

18 

586 

*  Determined  by  the  diastase  method,  without  previous  washing  with  water,  and 
calculated  as  starch. 


614 


DIET  m  DISEASE 


Table  I. — Analyses 


Manufacturer  and  Brand. 


1910    20 

1910  34 
1893    22 

1910  34 
1913 

1910    20 

1897  2i5 
1910  20 
1913 

1913 

1913 
1913 
1913 

1913 

1913 
1913 
1913 
1913 


1913 

1910  13 
1913 
1913 

1908  37 
1913 
1913 
1913 

1911  14 
1904  39 
1906    8 

1911     114 

1911    0-i 

1901      36 


Haed  Breads  a^d  Bakery  Products.     (cont.J 
Rademann's  Nahrmittelfabrik,  Frankfurt,  Diabetiker-Zwieback 

a  it  c£  a  li 

"  "  Erdnuss-Biskuits    

"  "  "  Kasestangen    

a  (C  a  IS 

Rademann's  Nahrmittelfabrik,  Frankfurt,  Sanitatszwieback 

Schelle,  Braunschweig,  Aleuronat-Kakes  

Seidl,  Miinchen,  Kleberzwieback 

Roman  Uhl,  Karlsbad,  Carlsbad-Water  Biscuits,  "Sprudel"  Brand  .... 

G.  Van  Abbott  &  Sons,  London,  Caraway  Biscuits  for  Diabetics 

"  "  "        Diabetic  Rusks  for  Diabetics 

"  "  "        Euthenia  Biscuits    

"  "        Gluten  Biscottes  or  Rolls  

"  "       Gluten  Bread  or  Slices  

G.  Van  Abbott  &  Sons,  London,  Gluten  Butter  Biscuits  for  Diabetica. . 

"  "  "         Ginger  Biscuits  for  Diabetics 

"  "  "         Midolia  Biscuits    

"  "  "        Walnut  Biscuits  for  Diabetics 

Breakfast  Foods.  ■ 

Brusson  Jeune,  Villemur,  France,  Farine  au  Gluten 

"  "  '■  "        Gluten  Semolina   

Farwell  &  Rhines,  Watertown,  N".  Y.,  Barley  Crystals 

"  "  "  "        Cresco  Grits 

Hazard's  Wheat  Protein  Breakfast  Food 

Health  Food  Co.,  New  York,  Manana  

Jireh  Diabetic  Food  Co.,  New  York,  Whole  Wheat  Farina 

"  "  "  "  Frumenty 

The  Kellogg  Food  Co.,  Battle  Creek.  Mich.,  Granola I 

Pure  Gluten  Food  Co.,  New  York,  Gum  Gluten  Breakfast  Food 1 

li  it  ii  a  tc      a  ft  a 

i<  (c  it  it  ti  ft  it  (t 

Granules V...... 

"  "  Pure  Gluten  Breakfast  Cereal 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 

OF  Diabetic  Foods. — Continued. 


615 


u 

s 

6 

o 

II 

<u 
60 
tS 

Li 

0. 
-.J 

0 
0 

■T3 

a 
0 

L. 

a 

c. 

0 

0 

a) 
Is 

< 

10 

CO 

a 
0 

u 

>< 

0) 

<u 

a 

0  0 

h  =s 

0) 

Weight    supplying 
same  amount  car- 
boll. vtl  rates  as   10 
gms.   wheat  bread. 

't, 
0 

"a  CO 

oa 

to 

Is 

c3  a 
0 

i4 

gms. 
110 

cts. 

cts. 

''c 

% 

% 

16.4 

% 

% 
37.6 

% 

% 

gms. 
14 

9.4 

2.2 

252 

5Lp 

11.9 

47.0 

10+ 

413 

.... 

19 

2J 

34.8 

..   1   39.1 

21.5 

9.0 

14 

489 

09 

2  2 

11.2 

50.5 

29.3 

10+ 

511 

's 

"49 

'35 

324 

67 

3.8 

9.3 

0.1   1  46.4 

337 

38.6 

11 

524 

10 

96 

17.5 

.  .    1  58.4 

9 

.  . 

49 

1.3 

19.9 

63  P 

10.8 

8+ 

429 

11 

"io8 

6  3 

148 

666 

78 

8 

396 

8 

170 

30 

'so 

8  1 

l'.7 

100 

0.2 

74  8 

5.2 

556 

7 

386 

36 

330 

72 

100 

6.7 

36 

35.6 

0.7 

159 

375 

8.6 

33 

544 

^i 

60 

48 

363 

108 

1.2 

.70.9 

0.3 

•160 

0.8 

12.6 

33 

355 

13 

256 

84 

149 

55 

3.4 

35.8 

1.4 

13.2 

40.7 

6.9 

40 

562 

12 

251 

72 

130 

10.5 

2.4 

51.6 

0.2 

33.0 

2.3 

29.8 

16 

359 

« s 

216 

72 

151 

10  6 

2.0 

54  1 

0.2 

30.9 

2.2 

27.4 

17 

361 

195 

60 

140 

61 

30 

44.1 

0.9 

127 

33.2 

9.0 

40 

526 

31 

423 

72 

77 

4  1 

3  4 

.34  6 

1.8 

16  7 

39.4 

10.9 

32 

560 

52 

517 

36 

32 

60 

43 

17  0 

4.1 

31.6 

364 

134 

16 

524 

29 

223 

60 

122 

44 

29 

20  9 

23 

12.3 

57.2 

Trace 

41 

648 

246 

25 

46 

109 

0.6 

33  9 

02 

53.8 

0.6 

48.8 

10 

356 

209 

30 

65 

97 

0  7 

17.2 

03 

71.6 

0.5 

64.9 

7 

360 

904 

25 

13 

99 

12 

11.5 

09 

75  2 

1.3 

62.7 

7 

359 

898 

25 

13 

11  1 

06 

17.8 

05 

68.6 

1.4 

54.1 

8 

358 

85 

07 

40.1 

49.7"" 

1.0 

13+ 

368 

'iss 

'25 

60 

102 

24 

37  6 

1.1 

468 

1.9 

31.6 

11 

355 

703 

15 

10 

62 

1  8 

12.9 

22 

746 

2.3 

59  5 

7 

.371 

674 

15 

10 

62 

1.4 

12.3 

1.1 

77.3 

1.7 

65.4 

7 

374 

370 

10 

12 

61 

23 

13.9 

06 

76  3 

0.8 

45.2 

7 

368 

9  5 

0.9 

54.4 

05 

33.9 

0.8 

30.4 

16 

360 

9  1 

1.1 

53.4 

03 

.34  5 

1.6 

*31.0 

15 

366 

465 

'26 

'26 

75 

12 

37  8 

04 

51.8 

1.3 

37.9 

10 

370 

457 

20 

20 

75 

15 

45.5 

03 

436 

1.6 

,32.3 

12 

371 

93 

07 

43  7 

03 

44.4 

1.6 

12 

367 

*  Determined  by  the  diastase  method,  without  previous  washing  with  water,  and 
calculated  as  starch. 


616 


DIET  IX  DISEASE 


Table  I. — Analyses 


1910 

13 

1910 

13 

1913 

1910 

13 

1913 

1913 

1906 

9 

1911 

14 

1901 

5 

1912 

18 

1899 

4 

1913 

1913 

1913 

1913 

1913 

1913 

1913 

1913 

1913 

1913 

1913 

1899 

4 

1913 

1902- 

-3  3 

1902- 

-3   3 

1902- 

-3   3 

1913 


1913 
1913 


1901      36 

1913 


Manufacturer  and  Brand. 


Macaroni,  Noodles,  Etc. 
Brusson  Jeune,  Villemur,  France,  Pates  aux  Oeufs  Macaroni  . 
"  "  •'  '•  "         "        "       Nouillettes 

"  ••  "        Petites  Pates  au  Gluten  .  .  . 

"  ••  •'  ••        Vermicelle  au  Gluten 

Jireh  Diabetic  Food  Co.,  New  York,  Macaroni 


Eugene  Loeb,  New  York,  Home  Made  Noodles 

Pure  Gluten  Food  Co.,  New  York,  Gum  Gluten  Macaroni 
'  "  "  "  "  "       Noodles    . 


rhe  Marvelli  Co. 


Detroit,  Mich.,  Macaroni 
"  "        Spaghetti 


Peanut  Butter. 

Atlantic  Peanut  Refinery,  Philadelphia ; 

1.  W.  Beardsley's  Sons,  New  York,  Acme  Red  Brand 

Beech-Nut  Packing  Co.,  Canajoharie,  NY" 

A.  C.  Blenner  &  Co.,  New  Haven   (Distributed  by) 

D.  W.  Brooke,  Newark,  N.  J 

Dillon  &  Douglass,  New  Haven   (Distributed  by),  Perfection 
H.  J.  Heinz  Co.,  Pittsburgh,  Pa 


rhe  Kellogg  Food  Co.,  Battle  Creek,  Mich. 


Francis  H.  Leggett  &  Co.,  New  York,  Premier 

MacLaren  Imperial  Cheese  Co.,  Detroit,  Mich.,  Eagle 

>Jut  Products  Co.,  New  Haven,  Penolia 

Peanolia  Food  Co.,  New  Haven,  Peanolia 

.  S.  Pierce  Co.,  Boston,  Acharis  Brand 

Average . 
Almond  Paste. 
hapman,   Chicago    


Henry  Heide,  New  York 


pencer,  New  York   

Average 

Nuts. 
California  Paper  Shell  Almonds,  edible  portion    (Sold  by  Chas.  Law- 
rence Co  ,  Boston )    

lireh  Diabetic  Food  Co.,  New  York,  Diatetic  Pine  Nuts  (Pignolias)  . .  . 
riie  Kellogg  Food  Co  ,  Battle  Creek,  Mich.,  Pine  Nuts 


rhe  Kellogg  Food  Co. 


Malted  Nuts. 
Battle  Creek,  Mich.,  Malted  Nuts 


Nashville  Sanitarium-Food  Co  ,  Nashville,  Tenn.,  Malted  Nut  Food. 


DISEASES  l.\   WHICH  DIET  J 8  A   I'JaMARY  FACTOR 

OF  Diabetic  Foods. — Continued. 


617 


"c 
6 

"o 

be  oJ 

IS 

o 

■6 

a 

o 

c. 
o 

< 

o 
o 

a 

'S 
o 

X! 

s 

a-  . 

k 

u 

■Si 

&4 

Weight    supplying 
same  amount  car- 
bohydrates as   10 
gms.   wheat  bread 

11 
'E 
o 

gms. 
220 

cts. 
45 

Cts. 
93 

% 

8.8 

% 

0.7 

% 
13.9 

% 

Tr. 

76.2 

% 

0.4 

% 

69.2 

gms. 

7 

364 

231 

30 

59 

8.7 

0.7 

14.4 

Tr. 

75.7 

0.5 

68.9 

7 

365 

259 

25 

44 

9.0 

0.8 

18.6 

0.2 

70.4 

1.0 

61.2 

8 

365 

449 

45 

45 

8.0 

0.8 

18.4 

Tr. 

72.4 

0.4 

65.8 

7 

367 

437 

25 

26 

8.8 

1.1 

16.9 

0.9 

71.4 

0.9 

58.8 

7 

361 

130 

20 

70 

9.8 

1.0 

41.8 

0.2 

41.7 

5  5 

36.7 

13 

384 

10.3 

0.7 

41.4 

0  3  !  46.3 

1.0 

*46.2 

11 

360 

118 

15 

58 

8.3 

1.1 

36.6 

0.2  1  51.4 

2.4 

42.0 

10 

374 

13.4 

0.5 

20.7 

64.8 

0.6 

8+ 

347 

15.5 

25 

50 

2.1 

4.0 

28.7 

23 

16.5 

46.4 

6.2 

32 

598 

416 

25 

27 

2  2 

4.4 

28.2 

1.7 

15.2 

48.3 

4.0 

35 

608 

109 

10 

42 

2.0 

3.5 

29.4 

1.9 

16  6 

46.6 

4.5 

32 

613 

126 

10 

36 

2.9 

4.0 

29.7 

1.2 

14.3 

47.9 

4.6 

37 

607 

171 

10 

27 

1.8 

3.8 

29  5 

1.5 

14.9 

485 

4.3 

36 

614 

666 

23 

16 

1.8 

44 

29  1 

1.8 

20.1 

42.8 

4.8 

26 

582 

90 

10 

50 

3.0 

3.9 

28.9 

17 

15.2 

473 

4.0 

35 

592 

92 

15 

74 

3  6 

3.3 

30  6 

15 

12.2 

48.8 

3.21 

43 

610 

311 

30 

44 

3.1 

3.0 

28.1 

1.4 

147 

49.7 

3.4 

36 

619 

469 

23 

22 

2.1 

4.0 

29.7 

1.7 

18.8 

43.7 

6.5 

28 

587 

199 

10 

23 

1.5 

3.8 

32.1 

17 

16.0 

449 

4.3 

33 

597 

218 

13 

27 

2.4 

3.9 

27.9 

15 

130 

51.3 

3.9 

41 

625 

25 

50 

2.0 

6.0 

29.9 

21 

13.3 

46.7 

5.6 

40 

593 

231 

25 

49 

1.7 

3.7 

28.7 

30 

14.6 

48.3 

5.1 

19 

608 

2.S 

10 

29.3 

l.S 

15.J,' 

4T.2 

Jf.G 

34 

604 

23.7 

1.4 

13.1 

36F 

25.5 

11.3 

15+ 

427 

22.0 

1.6 

12.7 

43  7 

20.0 

small 
very 

12+ 

406 

27.0 

1.7 

13.5 

31.6 

20.2 

small 

17+ 

416 

2^.2 

J.6 

13. J 

37.F 

23.9 

15+ 

4 16 

177 

13 

35 

3.5 

3.5 

18.4 

30 

16.3 

55.3 

0 

33 

637 

242 

40 

75 

2,0 

4.6 

39.7 

0.9 

3.4 

494 

451 

75 

75 

2.6 

4.5 

38.0 

1.1 

4.2 

49.6 

0 

156 
126 

617 
615 

2  6 

2.2 

23.7 

,  43  9^ 

27  6 

12-4- 

519 

25 

3.4 

1.7 

24.7 

27  5 

42.7 

3  4 

19 

593 

*  Determined  by  the  diastase  method,  without  previous  washing  with  water,  and 
calculated  as  starch. 


618 


DIET  I\  DISEASE 


Table  I. — Analyses 


1913 
1913 

1910  34 

1910  34 

1901  40 

1903  « 

1910  20 
1913 

1898  32 

1899  33 


1913 
1906    8 
1906    8 

1903    6 
1913 

1913 


1913 

1900     42 

1900    42 

1913 

1913 

1911     15 


The  Kelloffff  Food  Co.,  Battle  Creek,  Mich.,  Almond  Butter  (Sanitas)  . .    W 

u      °°  u  <■'  "  '■  '•  '•  .  .      ~ 


Manufacturer  and  Brand. 


1906 

8 

The  Kello^ 

1908 

37 

" 

1913 

« 

1906 

8 

« 

1906 

8 

a 

1906 

8 

" 

1906 

8 

a 

1913 

Nashville 

1913 

a 

1913 

a 

Other  Nut  Pkepabations. 


Nut  Bromose   (Meltose  and 

Nuts )     

Nut  Butter   (Sanitas)    .... 

Nut  Meal  "  

Nuttolene  "  .... 

Pro-tose  "  .... 


Nashville  Sanitarium-Food  Co.,  Nashville,  Tenn.,  Nut  Butter 
"  "  Nutcvsa     . . 

"  "  Nutfbda     .. 


Chocolate. 
Brusson   Jeune,  Villemur,   France,   Chocolat  with  Added  Gluten  a  la 

Vanille     

Fromm  &  Co.,  Dresden,  Conglutin-Diabetiker-Schokolade   

Groetzsch,  Frankfurt,  Esschokolade   (Orange)    

"  "  Kochschokolade     


Plasmon  Co.,  London,  Plasmon  Chocolate 


Rademann's  Nahrmittelfabrik,  Frankfurt,  Diabetiker-Chokolade 

If  t<  '(  "  '< 

Iroponwerke,  Miilheim,  Tropon-Chokolade   


Cocoa. 

harrasse  Gluto-Cacao  

Jireh  Diabetic  Food  Co.,  New  York,  Diabetic  Cocoa 


Plasmon  Co.,  London,  Plasmon  Cocoa 

Rademann's  Nahrmittelfabrik,  Frankfurt,  Diabetiker-Cacao   . 

Callard,  Stewart  &  Watt,  London,  Casoid  Chocolate  Almonds 


Miscellaneous  Products. 
Grustav  Muller  &  Co.,  New  York,  Dr.  Bouma  Sugar-Free  Fat-Milk 
Rose's  Diabetesmilch,  5%   

10%    

D.  Whiting  &  Sons,  Boston,  Sugar-Free  Milk  (ave.  3  analyses)    . .  . 
Health  Food  Co.,  New  York,  Kaffeebrod   


The  Kellogg  Food  Co.,  Battle  Creek,  Mich.,  Sanitas  Meltose 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 

OF  Diabetic  Foods. — Continued. 


619 


•i 

6 

o 

|| 

0) 
c9 

a 

P. 

P. 

1 
0 

T3 

0 
3 
0 

P. 

u 

0) 

0. 

0 

0 

S 

a 

< 

5  a. 

Oh 

c 

.a 
S 

0) 

h   <1> 

VH    be 

s  t 

°  s » 

J3 

zn 

% 
*3.7 

Weight     supplying 
same  amount  car- 
bohydrates as  10 
gms.   wheat  bread.       ) 

1 

OS 

Oj  0 

^0. 

gms. 

cts. 

cts. 

% 

0.9 

% 
2.9 

% 

22.6 

% 

3.9 

% 

8.2 

Vr 

61.5 

gms. 
65 

677 

2.3 

3.0 

21.7 

flX" 

61.5 

46+ 

686 

221 

30 

61 

14.0 

1.5 

17.1 

1.2 

39.4 

26.8 

'  3.2 

13 

467 

0.2 

2.9 

28.8 

3.7 

13.9 

50.5 

*9.1 

38 

625 

3.0 

2.2 

29.0 

2.0 

12.1 

51.7 

*8.9 

44 

630 

55.2 

2.2 

12.7 

1.8 

6.3 

21.8 

84 

272 

62.2 

1.5 

22.6 

0.9 

3.6 

9.2 

147 

188 

473 

17 

16 

1.9 

2.9 

28.0 

1.6 

13.0 

52.6 

3.8 

41 

637 

411 

15 

17 

57.0 

1.8 

12.9 

1.0 

6.3 

21.0 

Trace 

84 

266 

440 

15 

15 

62.3 

1.6 

20.8 

0.5 

6.8 

8.0 

Trace 

78 

182 

250 

90 

163 

2.6 

3.2 

15.9 

2.2 

26.4 

49.7 

9.2 

20 

617 

96 

40 

189 

4.0 

5.4 

17.6 

1.2 

32.7 

39.1 

4.3 

16 

553 

4.6 

2.3 

10.8 

4.4 

17.2 

60.7 

12.0 

31 

658 

10.9 

6.7 

25.3 
21.1 

5.9 

26.1 

25.1 

15.9 

20 

432 

3.5 

2.5 

20.2 
16.1 

0.7 

48.0 
9.6 

25.1 

Trace 

11 
55 

499 

"99 

'45 

206 

2.5 

3.2 

17.5 

2.3 

16.9 

57.6 

'  3.8 

31 

656 

1.7 

1.6 

18.2 

2.7 

49.9 

25.9 

11 

506 

1.8 

18.4 

? 

6.4 

6.7 

21.5 

3.1 

40.1 

22.2 

16.3 

13 

446 

3.1 

4.3 

20.6 

3.6 

50.6 

17.8 

*32.6 

10 

445 

7.3 

3.9 

19.1 

3.4 

47.9 

18.4 

*29.0 

11 

434 

8.9 

6.6 

52.8 

20.9 

10.8 

5.1 

25+ 

392 

"258 

80 

i41 

5.2 

5.9 

17.6 

3.0 

44.7 

23.6 

10.7 

12 

462 

•• 

107 

50 

212 

3.5 

3.1 

22.3 

3.2 

16.1 

51.8 

Trace 

33 

620 

<14 

.5  oz.) 

30 

91.8 

0.5 

2.4 

5.3 

57 

92.5 

0.2 

1.1 

1.2 

5.0 

442 

54 

^  , 

86.3 

0.2 

2.3 

1.2 

10.0 

442 

10"4 

' 

8  oz.) 

'25 

86.4 

0.7 

5.7 

Tr. 

7.2 

88 

.. 

351 

15 

19 

4.5 

2.2 

12.9 

6.4 

72.5 

1.5 

10.1 

"7 

355 

•• 

26.8 

0.5 

0.6 

72.1 

7 

291 

*  Determined  by  the  diastase  method,  without  previous  washing  with  water,  and 
calculated  as  starch. 


620 


DIET  7iY  DISEASE 


Table  Xllla:— 


3265      Waukesha  Health  Products  Co.,  Waukesha,  Wis.     Hepeo  Dodgers 

3200  *■               "             ''             "                     "               Hepco  Flour  for  Diabetics 

3309  Loeb's  Diabetic  Food  Bakery,  New  York.     Gluten  Luft  Bread   

3310  "  ■'             "           "               "                P.  and  L.  Genuine  Gluten  Bread. 

3312  "Sanity,"  Prag.     Aleuronat-zwieback  fiir  Diabetiker  

3311  •'     "  •'         Bretzels    

3313  "  "         Conglutin  Mandelzwieback  fiir  Diabetiker   

3325  "  "         Diabetiker-Bisquits  ohne  Mehl  und  ohne  Zucker 

3314  "  "         Diabetiker-Cakes     

3317  "  "         Echte  Delikatess-Salzstangen  fiir  Diabetiker   

3322  "  "         Echtes  Mandelgebiick  fiir  Diabetiker 

3315  "  "         Haferzwieback  (ungesiisst)  fiir  Zucker-  u.     Magenkranke 

3306  "  "   .      Karlsbader  Curzwieback  fiir  Diabetiker,  etc 

3307  "  ■'         Pokorny's  Echter   Diabetiker   Zwieback,   ohne  Mehl   und 
ohne  Zucker     

3308  ''  "         Saccharin-Oblaten  ohne  Zucker    

3316  Brah-Ma  (mfr.  name  not  given).     Sent  by  Eugene  Loeb,  New  York 

3320      "Sanity,"  Prag.     Diabetiker  Mandel-,  Nuss-  und  Schokolade  Bonbons 

3324  "  "         Laevulose  Schokolade   

3323  "  •"         Mendel-  u.  Nussschokolade  mit  Laevulose  fiir  Diabetiker. 

3326  "  "         Manit-Chocolate    

3486  Pure  Gluten  Food  Co..  New  York.     Hoyt's  Gum  Gluten  Dainty  Fluffs  No.  1 

3487  "  "         "       "             "               Hoyt's  Gum  Gluten  Flour,  Groiuid  .... 


DISEASES  IS    WHICH  DIET  IS  .1   PRIMAIiV  FACTOR 


621 


Diabetic  Foods. 

i  OlcU 

izaiiou  ai 

■j: 

< 

9 

p4 

c 

O  o 

;2;^ 

u 

0) 
.„   83 

ah 

K 

■M" 

C.'' 

fill 

_aj 

u 

Si 

5 
ft 

c 
o 

u 

> 
c 

5 

0  ^ 

4.0 

5.1 

42.9 

4.2 

22.4 

20.8 

Trace. 

26 

441 

S.b 

1.1 

34.1 

0.2 

47.4 

8.7 

Trace. 

24 

448 

42.2 

14 

25.8 

0.1 

27.8 

2.7 

40.1 

11 

404 

8.4 

20 

17.0 

0.3 

61.6 

10.7 

23.9 

19 

239 

7.2 

3.6 

12.8 

0.3 

55.4 

20.7 

49.3 

9 

411 

7.1 

2.3 

15.0 

0.3 

54.6 

20.7 

46.5 

10 

459 

8.4 

1.9 

25.8 

0.4 

45.3 

18.2 

42.4 

10 

465 

7.5 

1.8 

14.0 

0.5 

60.1 

16.1 

35.4 

12 

448 

69 

3.5 

12.7 

0.5 

54.1 

22.3 

52.0 

9 

441 

4.3 

2.9 

32.5 

0.9 

10.8 

48.6 

44.8 

10 

468 

8.2 

1.8 

14.9 

0.5 

58.7 

15.9 

4.0 

49 

611 

9.0 

1.8 

10.2 

0  2 

74.6 

4.2 

47.6 

9 

438 

4.6 

3.2 

.32.9 

0.9 

10.4 

48.0 

58.7 

7 

376 

5.7 

2.4 

,   16.8 

1.7 

41.7 

31.7 

3.6 

51 

605 

8.1 

2.9 

11.0 

1.3 

68.6 

8.1 

27.1 

13 

519 

18.4 

2.3 

12  5 

0.9 

37.lt 

28.8 

55.2 

8 

391 

40 

3  0 

11.4 

2.6 

35.6$ 

43.4 

Trace. 

+10.: 

I        +9.4 

14 

458 

3.1 

26 

12.0 

2  2 

262§ 

53.9 

6.2 

— 5.( 

)        —5.0 

15 

579 

4.2 

2  5 

10.0 

1.7 

37  911 

43.7 

4.3 

— 3.( 

)        —4.0 

20 

638 

7.2 

0.9 

86.0 

0.3 

5.0 

0.6 

4.8 

—6.^ 

I        —6.6 

14 

585 

8.5 

1.0 

41.4 

0.3 

47.4 

1.4 

5.0 

106 

369 

6.9 

5.4 

41.6 

4.1 

20.7 

21.3 

40.4 

11 

368 

*  6.5  ffms.  to  100  cc,  read  in  200  mm.  tube,  t  18.60%  total  sugars  as  dextrose. 
$17.55%  total  sugars  as  invert.  §14.31%  total  sugars  as  invert.  1121.32% 
total  sugars  as  invert. 


622  DIET  IN  DISEASE 

Table  IV:— 

Manufacturer  and  Brand. 


The  Dieto  Food  Co.,  New  York  City. 

Dieto  Baking  Powder 

"      Barley  Coffee   

"      Bread,  Pure  Whole  Wheat   

"      Cocoa   

"      Crackers    

"      Flour,  Pure  Whole  Wheat 

"      Nut  Cereal   

"      Pine  Nuts   

"      Rusks     

"      Wheat  and  Barley  Cereal   

"      Whole  Wheat  Brand  Macaroni 

Fromni  cC-  Co.,  Dresden. 

Conglutin  Drops  

Conglutin-Zwieback    

Karl  Goldscheider,  Karlsbad. 

Aleuronat-Conglutin  Cakes    

Butter-Brezeln     

Feinste  Cocosnuss-Biskuits  fiir  Diabetiker.     "3.6%  carbohydrates." 

Feinste  Vanille-Biskuits  fiir  Diabetiker.  "  "  

Honigkiichen  fiir  Diabetiker.  "  "  

Saccharin-Oblaten  ohne  Zucker    

Tee  Gebjick    

Zwieback    

Feinste  Dessert-Schokolade  fiir  Diabetiker.     "9.98%  carbohydrates."... 
Feinste  Mocca-Schokolade  fiir  Diabetiker.     "10.26%   carbohydrates."... 

Feinste  Xuss-Schokolade  fiir  Diabetiker.     "11.32%  carbohydrates." 

Feinste  Orange-Schokolade  fiir  Diabetiker.     "9.98%  carbohydrates." 

The  Health  Food  Co.,  New  York  City. 

Almond  Meal    •  • 

Alpha  Best  Diabetic  Wafer  

Diabetic  Biscuit  

Gluten  Flour  No.  1    

Gluten   Nuggets    

Glutosac  Bread  

"  Butter  Wafers   

"  Gluten  Flour    

"  Rusks     

"  Wafers,   Plain    

"  Zwieback     

Manana  Gluten  Breakfast  Food  

No    1  Proto  Puflfs 

No   2  Proto  Puffs  

Protosac  Bread   

Gluten  Flour    


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 


623 


Diabetic  Foods. 

i     -zi 

lO 

v 

8 

o 

"S 

d 
2; 

o 

0.  Ml      • 

^^           < 

I    i 

1    1 

< 

a 
'S 
o 

Em 

a 

O  o 

h  a 
. «  tc 

o 

Weight  supplyin 
same  amount  c 
bohydrates    as 
gms.  wheat  bre 

1 

II 

^0. 

oz.   ct 

s.   ct 

8. 

8.1    S 

5   7 

0    

12.94 

14.0    2 

0   5 

4   342 

3.08 

13.19 

9.i4 

63.87 

7.30 

17.72 

8 

374 

i 

15.1    ] 

2    ] 

3  40.42 

1.69 

9.67 

0.71 

47.15 

0.36 

36.57 

11 

231 

7.3   2 

0   f 

6   4.29 

5.40 

23.56 

4.87 

1|38.95 

22.93 

12.38 

14 

456 

42 

104   i 

50   4 

16   659 

1.75 

13.38 

0.98 

68.06 

9.24 

54.84 

8 

409 

79.0   e 

0   1 

2   7.85 

1  15 

14.75 

1.01 

73.13 

2.11 

62.44 

7 

371 

143   S 

0   2 

4   5.00 

1.95 

21.63 

1.22 

51.82 

18.38 

39.54 

10 

459 

7.9   4 

0   S 

1   2.23 

4.55 

39.69 

0.75 

2.76 

50.02 

0.00 

193 

620 

47 

12.7   f 

)0   7 

6   6.43 

1.50 

15.94 

0.98 

66.04 

9.11 

52.09 

8 

410 

36.3   [ 

to   1 

3   6.77 

1.68 

11.63 

2.00 

75.77 

2.15 

61.42 

7 

359 

•• 

13.4   I 

iO   [ 

16   9.81 

0.90 

13.88 

0.57 

73.70 

1.14 

58.72 

7 

361 

6.49 

5.23 

50.81 

0.23 

36.13 

1.11 

29.19 

15 

358 

.   4.48 

2.00 

14.25 

0.40 

57.62 

21.25 

29.70 

9 

479 

.   5.17 

1.25 

26.63 

0.08 

51.30 

15.57 

31.67 

10 

452 

5.16 

1.83 

10.50 

0.08 

67.57 

14.86 

43.93 

8 

446 

.   2.71 

2.73 

34.44 

0.88 

13.86 

$45.38 

None 

38(?) 

3.14 

2.85 

46.38 

0.55 

16.75 

$30.33 

None 

32(?) 

2.98 

3.05 

40.31 

1.00 

13.91 

$38.75 

None 

38(?) 

5.42 

2.43 

16.50 

1.95 

51.10 

22.60 

33.47 

10 

474 

3.44 

1.28 

7.00 

0.23 

60.79 

27.26 

18.00 

9 

517 

6.85 

2.70 

21.31 

0.23 

65.30 

3.61 

51.69 

8 

379 

.   2.17 

1.80 

11.38 

1.68 

t25.42 

57.55 

4.98 

21 

665 

220 

2.25 

10.19 

1.65 

t23.49 

60.22 

4.11 

23 

677 

3.37 

2.65 

14.63 

1.70 

t23.30 

54.35 

6.86 

23 

641 

2.38 

2.20 

11.44 

1.43 

t24.91 

57.64 

4.98 

21 

664 

.   ]( 

)0   7.16 

5.48 

49.13 

0.48 

15.91 

21.84 

0.00 

33 

457 

23 

3  6 

50   21 

22   761 

5.03 

67.06 

0.16 

11.73 

8.41 

1.26 

45 

391 

26 

9.6   i 

15 

12   5.80 

2.55 

35  94 

0.35 

46.53 

8.83 

39.77 

11 

409 

( 

50   7.65 

2.78 

75.69 

0.21 

12.79 

0.88 

7.09 

41 

362 

11.9 

35 

17   5.32 

2.75 

31.69 

0.27 

45.67 

14.30 

34.93 

12 

438 

i 

10.4 

15   i 

23  37.20 

1.64 

27.16 

0.82 

31.08 

2.10 

22.17 

17 

252 

24 

8.8 

30 

j5   5.44 

2.10 

31.13 

0.38 

47.01 

13.94 

38.93 

11 

438 

32.3 

37 

18   8.18 

1.20 

38.00 

0.48 

50.45 

I  69 

41  96 

10 

369 

14 

39 

15   ( 

52   666 

2.50 

39.31 

1  13 

46.96 

3  44 

33.64 

11 

376 

100 

6.0 

15 

10   724 

2.55 

42.63 

1.58 

44.26 

1.74 

29.55 

12 

363 

22 

6.4 

?0 

50   5.02 

2.50 

36.38 

0.85 

46.64 

771 

32.46 

11 

401 

10.1 

25 

10   7.56 

2.53 

42  63 

1.73 

43.56 

1.99 

29.87 

12 

363 

8 

4.4 

35   1 

27   8.71 

2.80 

7225 

0  40 

13.02 

2.82 

9.23 

40 

366 

8 

5.3 

25 

75   9.16 

2.60 

58.75 

0.40 

27.00 

2.09 

20  70 

20 

362 

1 

9.8 

20 

33  .30.70 

2.11 

29  82 

0.38 

35.19 

1  80 

27.66 

12 

276 

2 

0.2  1 

40 

21   816 

1.30 

45.94 

0.38 

42.26 

1.96 

31.50 

13 

370 

624  DIET  IN  DISEASE 

Analyses 


Manufacturer  aud  Braua. 


5368 
5375 
5364 
5360 
5374 


4379 
4377 
4378 


5249 


5389 

5387 
5388 
5390 
5385 
5386 
5391 
5392 


4374 
4375 


5379 
5397 
5399 
5398 
5394 
5393 
5396 
5395 
5377 
5378 


5400 


Protosac    KiisUs    

Protosoy  Diabetic  W  afers 

"         Soy   Flour    

Pure  Washed  Gluten   .  .  .  . 
Salvia  Almond  Sticks   .  .  . 


Ch.  Heudebert,  Paris. 

*Pain  d'Aleurone  pour  Diabetiques.     "5%  carbohydrates." 

*Pain  "Essentiel"  en  Biscottes 

*Pain  de  Gluten  pour  Diabetiques  


J.  Heinbockel  d-  Co.,  Baltimore,  Md. 
Diabeto  Bread  for  Diabetes 


Loeb's  Diabetic  Food  Bakery,  New  York  City. 

Chocolate  Almond  Bars   

Diabetic  Almond  Macaroons    

Bread  Sticks    

"         Chocolates     

"         Lady  Fingers   

"         Sponge  Cookies    

Gluten  Luft  Bread  

P.  &  L.  Genuine  Glubetic  Bread 


Mansfield  Laboratories,  Mansfield,  Mass. 

No  Name   ( square)    

No  Name   ( hexagonal )    


The  Pure  Gluten  Food  Co.,  Wew  York  City. 
Hoyt's  Gum  Gluten  Biscuit  Crisps 

"  "  "  Breakfast  Food  .... 
Flour,  50%    

"  "  "  "       Ground     

"  "  "       Granules     

"  "  "       Noodles     

"  "  "       Self  Raising  Flour    . 

"  "  "       Special  Flour    

No.  1  Dainty  Fluffs    

No.  2        "  "         


Battle  Creek  Sanitarium  Co.,  Battle  Creek.  Mich. 
80%  Gluten  Meal  


Phospho  Food  Co.,  Los  Angeles,  Cal. 
5555  I       Phospho  D.  &  D.  Special   


*  Sold  by  A.  Beauvais  &  Co.,  New  York  City,  and  John  Gilbert  &  Son,  New 
Haven. 


I 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 


625 


OP  Diabetic  Foods. — Continued. 


o 

c 
3 

1.-5 

is 

X 

MS"  a 

"3  »•■ 

d 

^  at 

oz. 

■X. 

0 
0 

a 

C 

c 

a 

< 

X 

c 
'3 
0 

u 

^ 

.^ 
S 

0) 

a 

0  u 

Si 
u. 

m 

Sill 

0;  cd  0  C 
>  «.=  W) 

0 

cts. 

Cts. 

10 

3.0 

15 

so 

7.21 

2.93 

39.69 

0.48 

46.69 

3.00 

35.89 

11 

373 

20 

5.7 

40 

112 

4.76 

3.50 

37.07 

1.80 

29.34 

23.53 

14.40 

18 

477 

50 

3.86  5.30 

42.88 

2.75 

26.03 

19.18 

1.80 

20 

448 

25 

7.03  0.58 

85.03 

0.40 

5.35 

1.01 

2.81 

99 

373 

1  7 

15.6 

75 

77 

2.63 

3.38 

22.31 

0.70 

41.04 

29.94 

28.29 

13 

523 

60 

10.2 

90 

141 

8.18 

4.43 

76.06 

0.71 

9.17 

1.45 

4.22 

58 

354 

50 

16.6 

80 

77 

7.67 

2.33 

26.38 

0.20 

62.22 

120 

49.89 

8 

365 

21 

14.3 

110 

123 

7.85 

3.96 

80.65 

0.16 

6.54 

0.84 

3.38 

81 

356 

33.47 

3.22 

8.55 

1.15 

52.12 

1.49 

40.39 

10 

250 

4 

2.0 

25 

154 

2.88 

3.77 

16.25 

4.32 

**31.78 

41.00 

5.74 

17 

501 

49 

4.4 

40 

145 

3.22 

2.98 

46.50 

1.53 

8.00 

37.77 

0.64 

66 

558 

10 

2.9 

15 

83 

8.72 

2.28 

50.44 

0.60 

34,52 

3.44 

24.04 

15 

371 

4 

2.6 

25 

154 

1.98 

3.85 

14.88 

4.90 

**22.97 

51.42 

0.92 

23 

014 

25 

1.4 

25 

286 

6.01 

2.75 

56.50 

0.35 

6.04 

28.29 

1.81 

88 

505 

32 

1.6 

25 

250 

6.92 

2.75 

54.69 

0.55 

4.98 

30.11 

1.24 

106 

510 

12 

14.4 

85 

94 

5.68 

2.05 

52.38 

0.63 

26.02 

13.24 

22.89 

20 

433 

1 

11.9 

15 

20 

30.07 

1.06 

38.77 

0.36 

25.09 

4.05 

19.15 

21 

294 

9.34 

5.53 

29.50 

0.43 

47.79 

7.41 

§34.20 

11 

376 

8.65 

4.84 

25.38 

0.47 

45.49 

15.17 

§31.10 

12 

358 

20 

3.8 

25 

105 

5.97 

1.70 

52.69 

1.08 

38.04 

0.52 

31.22 

14 

308 

16.5 

20 

19 

6.48 

0.60 

45.38 

0.28 

40.40 

0.80 

39.21 

11 

375 

6.61 

0.70 

49.69 

0.33 

41.52 

1.15 

37.07 

13 

375 

16.0 

18 

18 

8.21 

0.60 

41.94 

0.18 

48.14 

0.93 

42.61 

11 

309 

16.5 

20 

19 

6.64 

0.73 

42.69 

0.45 

48.80 

0.09 

41.93 

11 

372 

4.0 

15 

60 

8.21 

0.65 

40.50 

0.33 

49.08 

1.23 

41.82 

11 

309 

16  1 

18 

18 

7.30 

3.88 

42.09 

0.40 

44.98 

0.75 

38.98 

12 

357 

16.3 

30 

29 

5.63 

0.93 

90.09 

0.35 

1.68 

0.72 

2.17 

}15 

376 

19 

2.6 

40 

246 

7.04 

0.75 

79.94 

0.45 

11.28 

0.54 

10.74 

47 

370 

18 

2.4 
14.4 

25 

167 

7.45 

6.83 

0.68 

06.25 
84.00 

0.28 

24.87 

0.47 

21.85 

5.77 

21 

309 

8.74 

1.22 

13.69 

1.24 

72.92 

2.19 

58.57 

7 

366 

t3497   contains   10.95%   as   invert   sugar,   3494,    lO^o,   3495,   7.25%,   and   3490 
11.15%.     t  In  part  glyceral.     §  Possibly  in  part  due  to  the  copper-reducincr  power 
of  the  agar-agar  present.     H  Polarization  at  20°  C.  direct  +  1.5°,  after  inversion 
±  0.0°.     **  Polarization  at  20°  C.  direct  +  2.1°,  after  inversion  ±  0.0. 
40 


626 


DIET  IN  DISEASE 


Flour  and  Meal. 

Barker's  Gluten  Food,  A 

Barker's  Gluten  Food,  B 

Barker's  Gluten  Food,   C 

40  per  cent.  Gluten  Flour 

40  per  cent.   Gluten    

Gluten  Flour 

Gluten  Flour 

Cresco  Flour    

Special  Diabetic  Food    (Flour)    

Special  Diabetic  Food   (Flour)    

Special  Diabetic  Food   (Flour)    

Glutosac  Flour,   35  per  cent.  Proteids.  . 

Protosac  Flour,  40  per  cent.  Proteids.  . 

Pure  Washed  Gluten  Flour,  85  per 
cent.  Proteids,  6  per  cent.  Carbo- 
hydrates,  9  per  cent.  Water    

Jireh   Diabetic   Flour    

Wheat  and   Barley    

Wheat  and  Barley 

Flour    

Educator  Standard  Gluten  Flour 

Almond    Meal    

Vegetable  Glut«n,  20  per  cent.  Starch.  . 

Sojah  Bean  Meal,   5.5  per  cent.  Starch. 

Soja  Bean  Meal,  7.63  per  cent.  Starch. 

Hoyt's   Gum   Gluten    

Gum  Gluten,   Ground    

Gum  Gluten,   Self-raising 

(Jum  Gluten  Breakfast  Food 

Sanitas  Nut  Meal 

Casoid  Flour 

Bread,  Biscuit,   Rusk,  ett;. 

40  per  cent.  Gluten  Biscuit 

Potato  Gluten   Biscuit    

Pure  Gluten  Biscuit '. 

No.     1    Proto    Puffs,     78.86    per    cent. 

Protein,    6.71   Starch    

Salvia  Sticks 

Protosac  Bread,  40  per  cent.  Protein.  . 
Glutosac  Bread,  35  per  cent.  Proteids.  . 
Plain    Glutosac    Wafers.    33    per    cent. 

Proteids    

Glutona,   35   per  cent.   Proteids 

Glutosac  Zweiback.  35  per  cent.  Proteids 
Glutosac    Butter    Wafers,    35    per    cent. 

Proteids     

Protosac  Rusks,  40  per  cent.  Proteids.  . 
Glutosac  Rusk.  35  per  cent.  Proteids.  .  . 
Diabetic  Biscuit,  40  per  cent.  Proteids . 

Jireh  Whole  Wheat  Bread 

•Tireh  Diabetic   Biscuit    

.Tireh  Diabetic  Biscuit    

Jireh  Wheat  Nuts 

Jireh  Wheat  Nuts 

.Jireh  Diabetic  Rusks 

Dr.  .Johnson's  Gluten  Wafers    

Dr.  .Johnson's  Diabetic  Biscuit 

Dr.   Johnson's  Almond   Biscuit    

Dr.    Johnson's   Educator   Crackers,    Gre- 

seni   Gluten    

Dr.  Johnson's  Glutine.  Greseni  Gluten. 
Dr.     Johnson's    Gluten     Rusk,     Greseni 

Gluten    .  . 

Casoid  Biscuits 

Paate,   etc. 

Sanitas  Nut  Butter    

Sanitas  Nuttolene   . 

Sanitas  .Mmond  Butter    

Sanitas    Protose     


Manofacturer. 


Herman  Barker,   Somerville,  Mass. . 

Battle   Creek   Sanatarium   Food  Co 
Farwell  &  Rhines,  Watertown,  N.  Y 


The  Health  Food  Co.,  New  York. 


Jireh  Diabetic  Food  Co.,  New  York 

Johnson   Educator  Food   Co.,   Boston.... 

The  Health  Food  Co.,  New  York 

Theo.  Metcalf  Co.,   Boston 

The  Pure  Gluten  Food  Co.,  New  York.  .'. 


Sanitas  Nut  Pood  Co.,  Ltd.,  Battle  Creek, 

Mich 

Callard,   Stewart  &  Watt,  Ltd.,  London.. 

Battle   Creek   Sanatarium  Food   Co 


The  Health  Food  Co.,  New  York. 


Jireh  Diabetic  Food  Co.,  New  York. 


Johnson  Educator  Food  Co.,  Boston. 


Callard,  Stewart  &  Watt,  Ltd.,  London. 
Sanitas  Nut  Food  Co.,  Ltd..  New  York. 


I 


DISEASES  ly  WHICH  DIET  IS  A  PRIMARY  FACTOR 


626a 


Analysis  of  material  as  purohased. 


perct. 

0.22 
0.22 
0.22 
0.51 
1.38 
0.43 
0.46 
0.48 
1.93 
160 
1.28 
l.U 
0.66 


0.80 
1.30 
1.51 
1.64 
1,32 
0.95 
6.42 
0.65 
4.3b 

6.96 
0  99 
4.53 
1.07 

2.17 
2.46 

1.55 
0.82 
0.99 

1.32 

7.45 
1.44 
1.88 

3.54 
2.48 
2.45 
3.76 

2.01 
2.70 
3.10 
1.79 
2.01 
2.25 
2.33 
3.21 
3.06 
0.93 
1.89 
2.07 

2.94 
2.58 

2.98 
3.92 

2.85 
2.22 
2.93 


KiS 


per  ct. 

85.38 
84.38 
82.50 
40.25 
38.44 
11.37 
10.75 
11.12 
14.25 
14.20 
12.75 
34.06 
36.62 


62.40 
14.25 
11.75 
11.25 
12.12 
26.37 
50.62 
61.37 
39.87 
36.75 
31.82 
50.13 
37.87 
53.37 

29.00 
85.56 

35.75 
80.00 
80.25 


39.19 
32.47 
27.42 

29.44 
22.06 
32.50 
27.62 

40.87 
36.50 
28.12 
9.36 
14.75 
13.12 
19.00 
21.00 
14.62 
30.31 
25.31 
29.00 

23.00 

21.87 

22  12 
63!00 

28.81 
12.69 
22.62 


1.54  I  22.62 


perct. 
0.03 
0.02 
0.04 
0.15 
0.11 
0.25 
0.14 
0.05 
1.37 
1.07 
0.62 
0.97 
0.25 


0.16 
1.03 
1.59 
1.38 
1.11 
0.37 
2.86 
0.32 
3.85 

0.33 

0.48 
0.45 
0.33 

2.01 


0.13 
0.03 
0.16 

0.08 
1.91 
0.22 
0.42 

1.52 
0.30 
1.21 
1.63 

0.53 
0.88 
0.34 
0.61 
0.94 
1.22 
1.00 
1.16 
0.91 
0.29 
0.39 
0.46 

0.21 
0.56 

0.33 


3.66 

1.82 
3.92 
0.88 


perct. 
3.69 
4.64 
6.72 
47.42 
50.33 
74.38 
74.38 
74.73 
67.47 
70.11 
70.35 
52.13 
51.03 


29.51 
71.95 
73.56 
74.39 
72.63 
59.38 
15.96 
28.23 
25.09 

54.15 
39.62 

45.41 
34.48 

12.13 


54.10 
10.64 
10.31 

13.15 
24.06 
36.97 
36.11 

49.77 
58.60 
49.33 
49.41 

48.66 
51.63 
54.75 
48.08 
72.30 
70.57 
54.55 
46.41 
67.71 
61.25 
59.03 
54.34 

63.09 
67.86 

68.06 


13.97 
6.24 
8.11 
3.54 


perct. 
0.56 
0.60 
0.81 
1.18 
1.21 
0.90 
0.95 
0.88 
2.96 
2.75 
2.61 
1.57 
0.86 


per  ct. 

4.46 

6.03 

8.33 

46.85 

50.01 

71.51 

72.02 

58.33 
62.11 

49.33 
49.98 


0.91 

2.21 
1.87 
1.80 
1.84 
1.67 

15.63 
1.55 

19.06 

1.55 
1.86 
0.95 
1.64 

51.66 
0.50 

1.02 
0.36 
0.76 

1.02 

20.77 

1.60 

2.66 

9.60 
11.79 

6.89 
12.87 

2.03 

3.81 
9.02 
0.38 
3.66 
3.94 
15.55 
22.27 
5.01 
0.37 
7.48 
8.82 

4.61 
0.76 

0.28 
17.34 

50.54 

21.79 

61.52 

9.19 


perct. 
0.24 
0.24 
0.24 
0.57 
1.51 
0.49 
0.50 
0.55 
2.19 
1.78 
1.46 
1.27 
0.73 


27.51 
66.63 
66.22 


56.84 
7.18 

26.79 
8.95 

51.95 

38.55 
42.86 
41.04 

8.94 


52.64 
9.84 
9.07 

9.86 
18.66 
33.12 
29.90 

41.60 
54.88 
40.93 
41.24 

43.90 
42.48 
51.10 
43.83 
65.44 

50.13 


57.00 
54.85 
50.00 

57.86 
63.05 

63.27 
8.07 

9.09 

3.65 


Analysis  calculated  to  water-free  basis. 


perct. 

95.00 
93.90 
91.49 
44.97 
42.04 
13.02 
12.40 
12.75 
16.20 
15.83 
14..55 
37.90 
40.95 


0.85 
1.43 
1.67 
1.81 
1.48 
1.07 
7.02 
0.70 
4.75 

1.08 
1.06 
5.08 
1.17 

2.24 
2.73 

1.68 
0.89 
.1.07 

1.44 

7.98 
1.98 
2.74 

3.77 
2.60 
2.65 
3.94 

2.13 
2.82 
3.25 
2.94 
2.14 
2.47 
2.52 
4.41 
3.35 
0.99 
2.01 
2.18 

3.13 
2.75 

3.18 
4.25 

2.85 
4.96 
2.95 
4.08 


66.54 
15.71 
13.02 
12.44 
13.62 
29.72 
55.32 
66.64 
43.22 

35.83 
53.90 
42.45 
58.75 

29.90 
95.08 

3^63 

87.10 
86.79 

82.98 
41.96 
44.66 
40.07 

31.36 
23.17 
35.18 
28.99 

43.44 
38.21 
29.50 
15.39 
15.75 
14.41 
20.56 
22.33 
16.02 
32.54 
26.90 
30.63 

24.51 
23.36 

23.59 
68.35 

28.86 
28.35 
22.82 
59.90 


per  ct, 
0.03 
0.02 
0.04 
0.16 
0.12 
0.2^ 
0.16 
0.05 
1.55 
1.19 
0.70 
1.08 
0.27 


0.17 
1.13 
1.76 
1.52 
1.25 
0.41 
3.12 
0.34 
4.17 

0.37 
0.51 
O.C.O 
0.3G 


2.07 


0.14 
0.03 
0.17 

0.08 
2.04 
0.30 
0.61 

1.62 
0.31 
1.31 
1.71 

0.56 
0.92 
0.35 
1.03 
1.00 
1.34 
1.08 
1.23 
0.99 
0.31 
0.41 
0.48 

0.22 
0.59 


3.66 
4.06 
3.95 
2.33 


per  ct. 
4.11 
6.18 
7.44 
52.98 
55.01 
85.18 
85.78 
85.57 
76.70 
78.14 
80.31 
58.00 
57.09 


31.47 
79.30 
81.48 
82.24 
81.58 
66.92 
17.45 
30.64 
27.20 

60.98 
42.53 
50.91 
37.92 

12.51 


58.45 
11.59 
11.15 

14.39 

25.78 
50.86 
52.70 

53.02 
61.54 
53.40 
51.85 

51.72 
54.06 
57.44 
80.02 
77.21 
77.46 
59.01 
49.a5 
74.15 
65.77 
62.73 
57.40 

67.23 
72.49 

72.59 


14.00 
13.94 
8.20 
9.36 


per  ct. 
0.62 
0.66 
0.89 
132 
1.32 
1.03 
1.16 
1.08 
3.36 
3.06 
2.98 
1.75 
0.96 


0.97 
2.43 
2.07 
1.99 
2.07 
1.88 

17.09 
1.68 

20.66 

1.74 

2.00 
1.06 
1.80 

53.28 
0.56 

1.10 
0.39 
0.82 

1.11 

22.24 
2.20 
3.88 

10.23 

12.38 

7.46 

13.51 

2.15 
3.99 
9.45 
0.62 
3.90 
4.32 
16.83 
23.68 
5.49 
0.39 
7.95 
9.31 

4.91 
0.81 

0.29 

18.81 

50.63 
48.59 
62.08 
24.33 


per  ct. 
4.96 
6.71 
9.23 
52.35 
44.68 
81.90 
83.10 

66  30 
69.23 

54.88 
55.90 


29.33 
73.44 
73.36 


64.06 
7.85 

29.09 
9.70 

58.50 
41.44 
48.05 
34.16 

9.22 


56.88 
10.73 
9.81 

10.78 
19.98 
45.56 
43.65 

44.33 
57.64 
44.30 
43.29 

46.65 
44.47 
53.60 
72.05 
69.87 

54.24 


61.20 
58.29 
52.82 

61.65 
67.34 

67.47 
8.76 

9.10 

3.68 


*  Determined  by  the  diastase  method,  without  previous  washing  with  water,  and 
calculated  as  starch. 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR  627 

VON  NOORDEN'S  LISTS  OF  ALLOWABLE  FOODS 

The  following  four  tables  are  taken  from  von  Noorden's  article  in  The  Twentieth 
Century  Practice  of  Medicine: 

TABLE  I. 

First  Group — Unconditionally  Allowable  Foods. 

Fresh  meat:  All  the  muscular  parts  of  the  ox,  calf,  siieep,  pig,  horse,  deer, 
wild  and  domestic  birds — roasted  or  boiled,  warm  or  cold,  in  their  own  gravy  or 
with  mayonnaise  sauce. 

Internal  parts  of  animals:  Tongue,  heart,  brain,  sweetbreads,  kidneys,  mar- 
row-bones— served  with  non-farinaceous  sauces 

Preserved  meats:  Dried  or  smoked  meat,  smoked  or  salted  tongue,  ham, 
smoked  breast  of, goose,  American  canned  meats,  Australian  corned  beef. 

Fresh  fish:  All  kinds  of  fresh  fisli,  boiled  or  broiled,  prepared  without  bread- 
crumbs or  crackermeal,  and  served  with  any  kind  of  non-farinaceous  sauce, 
preferably  melted  butter 

Preserved  fish:  Dried  tish,  salted  or  smoked  fish,  such  as  codfish,  haddock, 
herring,  mackerel,  flounder,  salmon,  sardellen,  sprats,  eels,  lampreys,  etc.,  tinned 
fish,  such  as  sardines  in  oil,  anchovies,  etc. 

Fish  derivatives:     Caviare,  cod-liver  oil. 

Shell-fish:  Oysters,  mussels,  and  other  bivalves,  lobster,  crawfish,  crabs, 
shrimp,  turtle 

Meat-extracts:     Meat  peptones  of  all  kinds. 

Eggs:     Raw  or  cooked  in  any  way,  but  without  any  admixture  of  flour. 

Fats  of  all  kinds,  animal  or  vegetable 

Fresh  vegetables :  Green  lettuce,  eiidive,  cress,  spinach,  cucumbers,  onion,  leeks, 
asparagus,  cauliflower,  red  and  white  cabbage,  sorrel,  French  beans.  The  vege- 
tables, as  far  as  they  are  suited  to  this  mode  of  preparation,  are  best  cooked  with 
meat  broth  or  a  solution  of  Liebig's  extract  and  salt,  and  covered  plentifully  with 
butter,  lard,  suet,  or  goose-fat.     The  addition  of  flour  is  not  permissible 

Preserved  vegetables:  Tinned  asparagus,  French  beans,  pickled  cucumbers  in 
brine  or  vinegar,  mixed  pickles,  sauerkraut,  olives. 

Spices:  Salt,  white  or  black  pepper,  Cayenne  pepper,  curry,  cinnamon,  cloves, 
nutmeg,  English  mustard,  anise-seed,  caraway-seed,  parsley,  dill,  borage,  pimper- 
nel, laurel,  capers,  chives,  garlic,  etc  Many  of  these  spices  contain,  indeed,  a 
rather  large  percentage  of  carbohydrates,  but  they  are  added  to  the  food  in  such 
small  quantities  that  this  may  be  disregarded. 

Soups:  Clear  soups  and  broths,  with  or  without  eggs,  marrow,  fresh  or  dried 
vegetables   (Julienne),  clear  turtle  soup,  etc. 

Cheese:  Stracchino,  Neufchatel,  old  Camembert,  Gorgonzola,  and  all  other 
fatty  or  so-called  cream  cheeses. 

Beverages :  All  kinds  of  natural  or  artificial  carbonated  waters,  either  clear  or 
with  lemon-juice  and  saccharin  or  glycerin,  or  with  rum,  cognac,  whisky,  arrack, 
cherry  brandy,  plum  brandy,  Nordhiiuser,  rye  whisky,  etc.  Light  Moselle  or 
Rhine  wnnes,  claret,  or  Burgundy  in  amounts  prescribed  by  the  physician.  Coffee, 
black  or  with  cream,  without  sugar,  but  sweetened  with  saccharin  if  desired. 
Tea,  clear  or  with  cream  or  rum. 

TABLE  II. 
Second  Group. — Foods  Permissible  in  Moderate  Quantities. 

These  contain  carbohydrates,  but  in  so  little  amounts  that  they  need  not  be 
considered,  and  demand  no  compensation  by  a  reduction  in  the  allowance  of 
bread.  Some  of  the  articles  contain  a  rather  large  percentage  of  carbohydrates, 
but  the  absolute  quantity  in  which  they  are  consumed  is  small. 

The  amounts  here  given  liave  been  fixed  by  practical  experience,  and  it  will 
seldom  be  found  necessary  to  increase  them.  Of  the  dishes  here  given,  when  they 
are  allowed  at  all,  only  a  few — from  two  to  four — are  to  be  selected  each  day. 
It  is  possible  in  this  way  to  secure  a  great  variety  in  the  patient's  dietary. 

Internal  parts  of  animals:     Calves'  liver,  giblets — up  to  100  grams. 

Sausage:  Liver  sausage,  preferably  the  fatter  kinds,  liver  sausage  with  truffles, 
black  pudding — 90  grams.  Meat  sausage — 80  grams.  German  sausage.  Frank- 
furter sausage,  and  the  like,  brawn,  head-cheese,  sausage-meatballs — 100  grams. 


628  DIET  IN  DISEASE 

Patties:  Pate-de-foie  gras,  potted  beef,  ham,  tongue,  salmon,  lobster,  an- 
chovies, etc. — one-half  to  one  tablespoonful. 

English  sauces,  such  as  Worcestershire,  Harvey,  beefsteak,  anchovy,  lobster, 
shrimp,  India  soy,  China  soy — one  teaspoontul. 

Cream,  from  four  to  six  tablespoonfuls  a  day. 

Cocoa,  prepared  without  sugar — 25  grams. 

Cheese:  Emmentlial,  Romadur — 60  grams;  Gervis,  Stilton,  Brie,  Holland, 
Gruyere — 50  grams;  Edam,  Cheddar,  Gloucester,  Roquefort,  Parmesan — 30  grams; 
Cheshire — 25  grams 

Vegetables  {prepared  without  Jiour  or  sugar):  5  Teltower  turnips;  salsify, 
turnip-rooted  celery,  turnips,  cabbage,  pumpkin — 2  tablespoonfuls;  green  peas, 
beans,  carrots.  Brussels  sprouts — 1  tablespoonful:  H  artichokes;  1  truflfle; 
5  medium-sized  mushrooms;  1  tablespoonful  of  morels  or  other  edible  mush- 
rooms. 

Raw  vegetables:     S  radishes;   2  sticks  of  celery;   2  medium-sized  tomatoes. 

Xuts:  2  Avalnuts;  G  hazelnuts;  3  almonds;  a  thin  slice  of  cocoanut;  8 
Brazil  nuts. 

Fresh  fruits:  1  thin  slice  of  melon;  1  small  tart  apple;  1  or  li  peaches; 
1  spoonful  of  raspberries  or  strawberries;  4  spoonfuls  of  currants;  6  green  gages; 
12  cherries;  one-lialf  of  a  medium  sized  pear;  corresponding  amounts  of  other 
fresh  fruits. 

TABLE  III. 

Third  Group. — Conditionally  Allowable  Foods. 

The  condition  under  wliicli  dishes  from  the  following  table  are  permitted  is 
that  an  equivalent  shall  be  deducted  from  the  allowance  of  bread.  The  amounts 
given  below  are  the  equivalents  of  50  grams  of  white  bread,  containing  about 
30  grams  of  starch.  Advantage  is  taken  of  the  fact  that  larger  amounts  of  cer- 
tain carbohydrates  (cane-sugar,  milk-sugar,  fruit-sugar,  etc.)  may  be  allowed 
than  of  starch.  Some  of  the  dishes  given  in  the  preceding  table  appear  again 
here  because,  if  they  are  eaten  in  large  quantities,  an  account  must  be  taken 
of  the  carbohydrates  which  they  contain : 

1  liter  of  milk   (sweet,  sour,  or  buttermilk). 

li  liters  of  kumiss,  prepared  in  the  Russian  way. 

1  to  1^,  liters  of  ketir,  fermented  for  at  least  two  days  and  prepared  without 
the  addition  of  sugar. 

1  liter  of  cream. 

60  grams  of  rye  bread,  Graham  bread,  or  Hamburg  pumpernickel. 

65  grams  of  Westphalian  pumpernickel 

100  grams  of  aleuronat  bread,  prepared  after  Ebstein's  formula  (containing 
27  5  per  cent,  of  carbohydrates  and  32  per  cent,  of  vegetable  albumin;  the 
aleuronat  breads  are  very  variably  compounded). 

35  grams  of  zwieback  and  simple  coffee-cakes,  made  without  sugar. 

30  grams  of  English  cakes  of  various  sorts. 

30  grams  of   •Eichel-cacao"  (Stollwerck's) . 

50  grams  of  chocolate   (Stollwerck's). 

40  grams  of  chocolate  (French  make). 

40  grams  of  chestnuts  shelled  or  60  grams  unshelled. 

35  grams  of  cane-sugar,  brown  sugar,  or  rock-candy. 

35  grams  of  sweet  preserves. 

40  grams  of  fruit-sugar. 

40  grams  of  milk-sugar. 

50  grams  of  fruit-jam. 

40  grams  of  honey. 

40  grams  of  flour — wheat,  rye.  barley,  buckwheat,  millet,  or  oatmeal  or  corn 
meal. 

45  grams  of  bean,  pea,  or  lentil  flour. 

35  grams  of  starch  preparations,  potato,  wheat,  or  rice,  starch,  tapioca,  sago, 
maizene,  mondamin,  etc. 

35  grams  of  rice. 

35  grams  of  farinaceous  preparations — noodles,  macaroni,  oatmeal,  grits,  barley. 

50  grams  of  lentils,  peas,  beans   (weighed  dry). 
100  grams  of  green  peas. 


J 

i 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR  629 

180  grams  of  new  potatoes. 

14U  grams  of  winter  potatoes. 

120  grams  of  apples,  pears,  green  gages,  plums,  damsons,   mirabelles,  apricots, 

oliorries,  grapes 
200  grams  of  strawberries,  raspberries,  gooseberries,  mulberries,  currants,  black- 
berries, whortleberries,  blueberries. 
3  peaches. 
40  grams  of  tigs. 
3  bananas. 

A  handful  of  walnuts,  hazelnuts,  almonds,  or  Brazil  nuts. 
§  liter  of  beer  of  any  sort. 
^  liter  of  sweet  wine. 

TABLE  iV 
Fourth  (Jroup. — Especially  Valuable  Foods. 
The  great  value  of  the  following  articles,  of  which,  however,  tliere  is  but  a 
small  choice,  is  due  in  part  to  the  high  percentage  of  protein  and  in  part  to  that 
of  fat.  The  proportion  of  albumin  and  fat  is  given  for  each  100  grains  ot  tlie 
food-substance.  Some  contain  carbohydrates  also,  the  percentage  of  which  is 
given  for  the  sake  of  completeness,  but  its  nutritive  value  is  not  counted. 

100  Tj     .  •         p  *       Carbo-     Caloric 

Grams.  Protein      Fat      i^y^rate     value. 

Vegetable   oil    100  930 

Butter     1  85  0.5  830 

Bacon   i  salt  or  smoked)    10  76  748 

Devonshire   cream    2  57  2  538 

Cream  cheese   (Gervais,  Neufchatel,  Stilton, 

Stracchino,   etc. )     19  41  1  451 

German  sausage    (Cervelatwurst)    18  40  ..  446 

Ham    25  36  ..  437 

Cheddar  cheese   28  33  2  422 

Fat  pork    14  37  .  .  400 

Smoked  ox-tongue    24  32    ■  396 

Fatty  cheese    (average)    25  30  1.5  381 

Yolk  of  egg  16  31  0.5  354 

Fat   goose    16  30  .  .  345 

Fat  beef  and  mutton  17  2!)  337 

Brie  cheese    19  26  1  320 

Fresh   water-eel    13  28  . .  312 

Smoked  mackerel      19  22  382 

Caviare     31  16  ..  276 

Cream      4  23  4  230 

Fat  salmon   i  fresh  or  smoked)    22  13  .  .  210 

Hens'  eggs  (weighed  with  the  shells)    12  10  0  5  142 

Carbohydrate  Equivalents. — Various  tables  have  been  advised  to 
show  at  a  glance  the  amounts  of  different  articles  of  diet  that  can  be 
substituted  for  given  amounts  of  ordinary  w^heat  bread.  One  of  the 
most  practical  of  these  is  that  of  Carter  (The  Medical  Record,  1911), 
which  shows  the  amounts  as  compared  with  7.5  to  75  grams  (i/4  to  2^0 
ounces).  The  carbohydrate  tolerance  is  determined  usually  by  giv- 
ing wheat  bread,  and  should  it  be  desired  to  convert  this  quantity 
into  other  articles  of  food  the  quantities  can  be  determined.  The 
equivalents  for  any  given  day  should  not  exceed  the  total  quantity 
of  white  bread  that  would  be  allowed.  For  example,  if  it  has  been 
determined  that  45  grams  of  white  bread  could  be  allowed,  the  fol- 
lowing diet  should  be  substituted,  as  it  represents  the  carbohydrate 
equivalents : 


630 


DIET  IN  DISEASE 


Potato     22.0  gm.  equals 

Oatmeal     40.0    " 

Cornmeal     20.0    " 

Carrots      65.0    "         '" 

Orange     40.0    " 

187.0  45.0 


7.5 

?m. 

of  white  bread 

7.5 

" 

<i     << 

15.0 

" 

a                  << 

7.5 

" 

a                   « 

7.5 

" 

((        i( 

White  bread. 


Potato 

Hominy  (cooked) 

Oatmeal  (cooked) 

Rice  (cooked) 

Farina  (cooked) 

Shredded  wheat 

Macaroni  (cooked) 

Brown  bread 

Corn  bread 

Rye  bread   

Graham  bread 

Biscuit 

Roll,  French 

Roll,  Vienna 

Crackers  (Boston) 

Crackers  (Graham) 

Crackers  (oyster) 

Pretzel 

Chocolate  cake 

Gingerbread 

Sponge  cake  

Cookies  (molasses) 

Lady  fingers 

Doughnuts 

Almond  meal 

Vegetable  gluten 

Soya  bean  meal 

Milk  (whole) 

Cream « 

Grape-fruit,  weighed  with  skin 

Beer  (Pilsner) 

Apple  pie 

Custard  pie 

Lemon  pie 

Rice  pudding 

Tapioca  pudding 

Lima  beans        

Beets  (cooked) 

Carrots 

Corn  (canned  or  green) 

Egg-plant 

Parsnips 

Green  peas 

Potatoes  (sweet) 

Turnips 

Apples 

Bananas    

Grapes 

Muskmelon 

Oranges 

Peaches  

Pears 

Prunes   

Strawberries 

Watermelon 

Peanuts 

Chocolate 


6 
6 

7 

7 

7 

6 

6 

8 

65 

17 

50 

112 

112 

187 

125 

10 

17 

12 

14 

15 

50 

65 

65 

02 

90 

35 

30 

10 

56 

45 

20 

32 

112 

40 

50 

30 

24 

65 

225 

20 

15 


44 

50 

80 

30 

50 

10 

60 

20 

20 

18 

18 

16 

16 

16 

12 

12 

12 

12 

14 

14 

14 

12 

12 

16 

130 

34 

100 

224 

224 

375 

250 

20 

34 

24 

28 

30 

100 

180 

130 

44 

180 

70 

60 

20 

112 

90 

40 

64 

224 

80 

100 

100 

48 

130 

450 

40 

30 


1  oz.  or 

IJoz.  or 

2  oz.  or 

30  gm. 

45  gm. 

60  gm. 

88 

132 

176 

100 

150 

200 

160 

240 

320 

60 

90 

120 

100 

150 

200 

20 

30 

40 

120 

180 

240 

40 

60 

80 

40 

60 

80 

36 

54 

72 

36 

54 

72 

32 

48 

64 

32 

48 

64 

32 

48 

64 

24 

36 

48 

24 

36 

48 

24 

36 

48 

24 

36 

48 

28 

42 

56 

28 

42 

56 

28 

42 

56 

24 

36 

48 

24 

36 

48 

1   32 

48 

64 

260 

390 

520 

68 

102 

136 

200 

300 

400 

448 

672 

896 

448 

672 

896 

750 

n25 

1150 

300 

450 

600 

40 

60 

80 

68 

102 

136 

36 

60 

72 

56 

84 

112 

60 

90 

120 

200 

300 

4O0 

260 

390 

520 

260 

390 

520 

88 

132 

176 

360 

540 

720 

140 

210 

280 

120 

180 

240 

30 

50 

60 

224 

336 

448 

180 

270 

360 

80 

120 

160 

128 

192 

256 

448 

672 

160 

240 

320 

200 

300 

400 

200 

300 

400 

96 

144 

192 

260 

390 

520 

900 

80 

120 

160 

60 

90 

120 

2ioz.  or 
75  gm. 


220 
250 
400 
150 
250 

50 
300 
100 
100 

90 

90 

80 
.    80 

80 

60 

60 

60 

60 

70 

70 

70 

60 

60 

80 
650 
170 
500 
1120 
1120 
1875 
850 
100 
170 

96 
140 
150 
500 
650 
650 
220 
900 
350 
300 

80 
560 
450 
200 
320 

400 
500 
500. 
240 

650  •: '• 

200  ■^"■' 
150 


GOUT  AND  GOUTINESS 


Sydenham  said:  "Great  eaters  are  liable  to  gout,  and  of"  ese 
the  costive  more  especially.  Eating  as  they  are  used  to  eat  whv.  .  in 
full  exercise,  their  digestion  is  naturally  impaired.  Even  in  these 
cases  simple  gluttony  and  the  free  use  of  food,  although  common 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR  631 

incentives,  by  no  means  as  frequently  pave  the  way  for  gout  as  reck- 
less, inordinate  drinking."  This  statement  is  as  near  the  truth  as 
anything  that  has  been  said  since. 

The  causes  of  gout  are  to  be  considered  then  as  due  to  the  fol- 
lowing : 

1.  Alcoholism,  of  which  Garrod  wrote:  "With  an  absence  of  alco- 
hol in  any  shape,  coupled  with  an  absence  of  hereditary  predisposi- 
tion derived  from  alcohol-drinking  ancestors,  gout  would  practically 
be  unknown. ' ' 

2.  Overeating,  which  some  observers  have  placed  on  a  level  with 
overdrinking ;  the  one  usually,  however,  accompanies  the  other  in  those 
who  suffer  from  "exposure  to  luxury."  Food  unearned  by  physical 
exertion  is  the  food  that  usually  causes  the  trouble,  although  gout 
occasionally  occurs  in  athletes  who  take  an  abundance  of  exercise. 
The  latter  class  of  patients  generally  suffer  for  the  sins  of  their  an- 
cestors, for  gout  follows  the  old  Mosaic  law. 

3.  Heredity. — Gout,  as  is  well  known,  is  a  family  disease,  and  pre- 
sents itself  either  as  true  gout  or  in  the  form  of  an  arthritic  or  rheu- 
matic tendency. 

4.  Indigestion  is  a  potent  factor  in  the  causation  of  gout.  It  has 
been  said  that  "Gout  is  generally  acquired  with  the  help  of  a  sound 
stomach,"  but  the  stomach  rarely  remains  sound  for  any  length  of 
time. 

5.  Constipation  is  a  factor  not  to  be  overlooked.  The  gouty  not 
only  prove  to  be  costive,  but  suffer  from  the  effects  of  the  constipa- 
tion, a  fact  to  be  borne  in  mind  in  arranging  diet-lists  for  the  gouty. 

6.  Workers  in  lead  are  especially  prone  to  gout.  Mental  work, 
while  it  does  not  cause  gout,  may  lead  to  it  indirectly.  As  Ewart 
says :  "It  does  not  fulfil  the  letter  of  the  law  that  we  shall  earn  our 
own  bread  by  the  sweat  of  our  brow. ' ' 

The  physiology  of  gout  is  still  shrouded  in  considerable  mystery. 
As  early  as  1848  Garrod  showed  that  the  blood  of  gouty  persons  con- 
tained abnormal  quantities  of  uric  acid.  This  has  been  confirmed  by 
many  observers.  A  discussion  of  uric  acid,  and  the  various  theories 
concerning  it  and  gout  need  not  be  considered  here,  as  the  ideas  of 
investigators  have  changed  rapidly  during  the  past  few  years,  and 
doubtless  will  continue  to  do  so.  Those  interested  should  consult  the 
r-  .ent  articles  by  Brugsch  and  Schittenhelm,  Schmidt,  Magnus-Levy, 
<-.ud  others. 

It  is  agreed  that  the  essential  factor  in  the  production  of  gout  is  a 
disturbance  of  purin  metabolism.  (See  same.)  The  purin  bodies 
are  a  group  of  chemical  compounds  containing  CjN^.  Uric  acid  is 
tL  -nost  important  of  these,  but  there  are  others,  as  xanthin,  hypox- 
aL  .in,  caffein,  thein,  theobromin,  guanin,  and  adenin.  The  purin 
i/odies  found  in  the  urine  may  be  either  endogenous  in  origin,  that 
is.,  those  formed  in  the  body ;  or  exogenous,  as  those  taken  in  the  body 


632  DIET  IN  DISEASE 

as  food.  Purin  metabolism  is  supposed  now  to  be  carried  out  through 
the  agency  of  several  different  enzymes  which  are  in  various  organs 
of  the  body,  and  there  are  different  enzymes  for  each  form  of  purin. 
The  endogenous  purins  are  formed  from  the  catabolism  of  the  nuclei 
of  the  cells,  and  this  goes  on  quite  independent  of  the  purin  bodies 
introduced  in  the  food,  so  that  even  if  a  gouty  individual  is  kept 
on  purin-free  food  for  months,  uric  acid  may  be  demonstrated  in 
appreciable  quantities.  In  normal  individuals  fed  on  purin-free  diet 
the  blood  is  free  from  uric  acid. 

In  gouty  individuals  there  is  apparently  a  slow  formation  of  uric 
acid  from  nucleic  acids;  a  slow  destruction  of  uric  acid;  delayed  ex- 
cretion of  the  uric  acid  through  the  kidney,  and  as  a  consequence 
of  these  an  increase  in  the  monosodium  urate  in  the  blood  to  even 
more  than  8  milligrams  per  100  c.c.  During  the  attack  of  gout  the 
amount  of  uric  acid  in  the  urine  is  increased,  but  just  before  an  acute 
attack  and  just  after  it  the  amount  is  decreased.  Uric  acid  is  also 
found  to  be  increased  in  the  blood  in  pneumonia,  chronic  interstitial 
nephritis,  and  myelogenous  leukemia. 

In  the  diagnosis  of  gout  the  estimation  of  the  urate  in  the  blood 
and  the  quantitative  estimation  of  the  uric  acid  in  the  urine,  on  a  diet 
free  from  purin  nitrogen  and  after  the  addition  of  purin-containing 
foods,  have  been  found  of  value.  The  method  of  von  Noorden  is  to 
place  the  patient  on  a  purin-free  diet,  and  estimate  the  endogenous 
uric  acid  in  the  urine.  Then  400  grams  of  beef,  weighed  raw,  are 
given  on  two  successive  days,  150  grams  at  breakfast  and  250  grams 
at  noon.  Von  Noorden  estimates  the  400  grams  of  beef  to  contain 
0.24  gram  of  purin  bodies,  half  of  which  disappears  in  the  body,  but 
the  remainder  should  be  eliminated  in  the  urine  either  as  uric  acid 
or  purin  bases.  Normally,  the  elimination  of  this  amount  takes 
place  during  the  two  days  of  the  experiment  or  a  day  or  two  later, 
but  in  gout  there  may  be  a  considerable  retardation.  If  there  is 
retention  of  purin  nitrogen  in  the  body,  the  amount  of  food  contain- 
ing it  should  be  reduced.  A  patient  will  often  tolerate  smaller 
amounts  with  complete  elimination,  when  larger  amounts  cause  reten- 
tion. The  tolerance  and  the  allowance  of  purin-containing  foods  may 
thus  be  determined,  and  the  case  studied  much  in  the  same  way  as  the 
tolerance  for  carbohydrate  as  followed  in  diabetes.  A  simple  method 
of  estimating  the  uric  acid  in  the  urine  is  by  the  purinometer  of 
Walker  Hall,  which  depends  upon  the  precipitation  of  the  uric  acid 
with  a  silver  solution,  and  the  reading  of  the  amount  of  settled  pre- 
cipitate in  a  specially  graduated  tube.  The  exact  degree  of  accuracy 
of  this  method  has  yet  to  be  determined. 

The  principal  foods  containing  purin  bodies  are  meats,  fish,  peas, 
beans,  asparagus,  onions,  mushrooms,  tea,  coffee,  chocolate,  and  per- 
haps oatmeal.    Milk,  cheese,  butter,  and  eggs  do  not  contain  purin 


DISEASES  IX  WHICH  DIET  IS  A  PRIMARY  FACTOR 


633 


bodies.     Eggs  cause  an  increase  in  the  amount  of  uric  acid  excreted, 
while  alcohol  affects  individuals  differently  in  this  respect. 

The  following  tables,  taken  from  Walker  Hall's  book,  '"The  Puriu 
Bodies  of  Food  Stuffs,"  show  the  amounts  of  purin  bodies  in  various 
food  materials : 


Cod     

Plaice 

Halibut 

Salmon 

Tripe 

Australian  mutton  . 
English  mutton  .  . 
Loin  of  veal  .  . 
Neck  of  veal  .... 
Loin  of  pork  .... 
Neck  of  pork  .  .  . 
Ham    ...... 

Ham  fat 

Ribs  of  beef   ... 
Sirloin  of  beef  .    . 

Steak 

Liver  

Thymus  (sweetbread) 

Chicken      

Turkey   

Rabbit 


Percentage 

Average 

Calculated 

Undried  as 

of  purln 

percentage 

as  puriu 

grams  per 

nitrogen. 

ofnitrogen. 

bodies. 

kilo. 

0.0219 

0.0233 

0.0582 

0.582 

0.0334 

0.0318 

0.0795 

0.795 

0.0405 

0.0408 

0.1020 

1.020 

0.0482 

0.0466 

0.1165 

1.165 

0.0235 

0.229 

0.0572 

0.572 

0.0365 

0.0386 

0.0965 

0.965 

0.0411 

0.0454 

0.0465 

0.1162 

1.162 

0.0300 

0.0485 

0.0485 

0.1212 

1.212 

0.0257 

0.0227 

0.0567 

0.567 

00505 

0.0492 

0.1155 

1.155 

0.0419 

0.0455 

0.0455 

0.1137 

1.137 

0.0506 

0.0522 

0.1305 

1.305 

0.0826 

0.0826 

0.2065 

2.066 

0.1125 

0.1101 

0.2752 

2.752 

0.4025 

0.4025 

1.0063 

10.063 

0.0546 

0.0518 

0.1295 

1.295 

0.0504 

0.0504 

0.1260 

1.260 

0.0305 

0.0380 

00970 

0.970 

Purins  as 

grains  per 

pound. 


4.074 
5.565 
7.140 
8.155 
4.007 
6.755 

8.137 

8.487 
3.969 
8.085 

7.959 

9.135 

14.455 

19.264 

70.431 

9.065 

8.820 

6.314 


Certain  meats  appear  richer  in  purins  than  others  but  with  the 
exception  of  liver  and  sweetbread,  when  the  amount  of  each  sort  neces- 
sary to  provide  the  requisite  amount  of  protein  or  the  feeling  of 
satisfaction,  is  calculated,  there  is  not  much  difference  between  the 
species. 

The  legumes — oatmeal,  asparagus,  and  potatoes — it  will  be  noted 
contain  some  purin  bodies. 

Various  beverages  contain  purin  bodies,  especially  tea,  coffee,  and 
cocoa. 

The  purin  bodies  in  coffee,  tea,  and  chocolate  are  largely  methyl 
purins,  and  they  do  not  undergo  the  same  metabolic  changes  as  the 
others,  and  they  need  not  be  excluded  from  the  diet  of  the  gouty  as 
rigorously  as  the  other  forms.  Some  authorities,  however,  advise  that 
caffein-free  coffee  be  used.  Alcohol  is  apparently  injurious  on  ac- 
count of  its  retarding  purin  metabolism.  There  is  a  difference  of 
opinion  concerning  the  purin  content  of  oatmeal. 

Another  suggestion  that  has  been  made  by  Cohn  is  to  avoid  foods 
containing  much  sodium  and  to  use  foods  containing  potassium,  as 
rice.     These  potassium-containing  foods,  he  believes,  act  by  aiding  in 


634 


DIET  IN  DISEASE 


Purin  bodies 
(grains  per  pint) 

Tea 1.2 

Coffee 1.7 

Chocolate 0.7 

Cocoa 1.0 


Purin  bodies 
(grams  per  liter). 

Lager  Beer 0.125 

Pale  ale 0.145 

Porter 0.156 


White  bread      .    .    . 

Oatmeal 

Rice    ....... 

Pea  meal        .    .    .    . 

Beans  (haricot)    -    . 

Lentils        

Lentils  (malted)  .    . 
Potatoes     .    .    .    .    , 

Onions 

Tapioca  .    .    .    ,    . 
Cabbage      .    ,    .    . 

Lettuce 

Cauliflower    .    .    ■ 
Asparagus  (cooked) 


Percentage 

Percentage 

calculated 

of  purin 

as  purin 

Grams  per 

nitrogen. 

bodies. 

kilo. 

No    trace. 

0.0212 

0.0530 

0.530 

No    trace. 

0.0156 

0.0390 

0.390 

0.0250 

0.0637 

0.6375 

0.0250 

0.0637 

0.6375 

0.0150 

0.0375 

0.3755 

0.0008 

0.0020 

0.0200 

0.0031 

0.0090 

0.090 

No    trace. 

II 

II 
0.0086 

0.0215 

0.215 

Grains  per 
pound. 


3.4563 

2.5413 
4.1661 
4.1661 
2.3340 
0.1400 
00630 


1.5050 


the  excretion  of  the  sodium.  The  same  is  accomplished  by  the  use  of 
potassium  salts  and  by  acids.  Large  doses  of  hydrochloric  acid  taken 
over  long  periods  of  time  have  been  strongly  recommended.  The 
tendency  of  modern  therapy  in  gout  is  away  from  the  use  of  alkalis 
as  formerly  given.  This  is  particularly  true  of  the  treatment  of  those 
cases  in  which  there  is  subacidity. 

Exercise,  if  properly  supervised,  is  very  useful,  and  the  drinking  of 
large  quantities  of  water  is  usually  advised,  as  it  aids  materially  in 
excretion.  It  may  be  taken  hot  when  the  stomach  is  empty  if  it 
interferes  with  digestion  or  if  there  is  a  tendency  to  obesity.  The 
quantity  of  fluid  administered  should  be  duly  considered  with  regard 
to  the  heart  action. 

The  arrangement  of  the  diet  for  the  gouty  is  attended  by  many 
difficulties.  Many  gouty  persons  are  well-to-do,  and  have  been  accus- 
tomed to  rich  food,  and  they  do  not  care  to  give  it  up.  They  suffer 
from  many  idiosyncrasies,  some  real,  but  more  fancied.  There  can, 
however,  be  no  question  that  what  will  cause  trouble  in  one  gouty 
patient  may  be  taken  with  impunity  by  another.  If  the  patient  is 
affected  with  any  other  disease  in  addition  to  his  gout,  this  will  also 
have  to  be  taken  into  account  in  arranging  the  diet.  Heart  disease, 
arteriosclerosis,  and  chronic  nephritis  are  not  uncommon,  particularly 
in  the  cases  of  long  standing. 

In  a  general  way  it  may  be  stated  that  a  varied  and  simple  diet  of 
plainly  prepared  foods  is  the  best. 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR  635 

Sydenham  wrote :  ' '  The  more  closely  I  have  thought  upon  gout, 
the  more  I  have  referred  it  to  indigestion."  This  suggests  the  second 
indication — the  relief  of  dyspepsia.  Anything  that  will  improve  the 
digestion  of  the  patient  will  add  to  his  comfort. 

Preventive  Treatment. — Individuals  with  a  gouty  tendency  will 
do  well  to  follow  a  dietary  such  as  is  suggested  for  chronic  gout. 
Children  of  gouty  parents  or  of  gouty  ancestry  should  receive  a 
carefull}'  regulated  diet  from  childhood.  Sugars  and  sweets  should 
be  used  sparingly,  alcohol  should  be  prohibited,  and  tea  and  coffee 
taken  moderately,  if  at  all,  and  not  until  some  time  after  puberty. 
In  a  general  way  a  simple  varied  diet  should  be  allowed  in  which  the 
purin  nitrogen  does  not  figure  too  prominently.  Restrictions  in  diet 
are  not  apt  to  be  followed  unless  there  has  been  an  attack  of  the 
disease  or  of  one  of  the  allied  affections,  as  asthma  or  eczema.  Out- 
door exercise  is  of  great  help. 

Diet  in  Acute  Gout. — The  diet  in  the  young  and  the  plethoric  will 
differ  from  that  in  the  old  and  asthenic. 

In  a  primary  paroxysm  the  food  should  be  light,  and  preferably  in 
a  fluid  form.  Plenty  of  water  should  be  given,  and  in  the  full  blooded 
there  is  no  objection  to  withholding  all  food  for  a  short  time.  In 
the  weak  and  the  aged  food  should  be  given  at  regular  intervals :  milk, 
bread  and  milk,  farinaceous  foods,  especially  rice.  Sago  and  tapioca 
and  similar  foods  may  be  used.  Eggs  may  be  added  next  if  they 
agree,  and  vegetable  soups,  potato,  carrots,  and  cauliflower  may  be 
given.  The  return  to  the  regular  diet  should  be  made  gradually, 
adding  butter,  cream,  bacon,  fruit,  then  boiled  (white)  fish.  The 
plainer,  more  easily  digested  meats  may  be  added  last  of  all.  All 
the  foods  containing  purins  in  any  quantity-  should  be  avoided  for 
some  time.  If  it  is  possible  to  estimate  the  purin  tolerance,  as  sug- 
gested above,  it  will  give  a  good  guide  as  to  the  amount  to  be  allowed. 
If  this  cannot  be  done  the  diet  will  have  to  be  regulated  according  to 
clinical  observation.  Purin  fast  days,  from  one  to  six  a  week,  accord- 
ing to  the  condition  of  the  patient  and  his  excretion,  is  an  easy  and 
convenient  way  of  controlling  the  intake  of  purin  foods.  In  alco- 
holics, should  it  be  deemed  necessary,  small  amounts  of  well  matured, 
pure  whisky,  well  diluted  with  water,  may  be  given.  The  minimum 
amount  needed  should  be  used,  and  none  at  all  if  it  can  be  dispensed 
with  without  producing  serious  symptoms.  Moderate  drinkers  and 
temperate  people  should  not  take  alcohol  at  all. 

Diet  in  Chronic  Gout  and  Goutiness.— The  gouty  patient  should  be 
given  definite  directions  as  to  what  is  allowable,  and  if  he  can  be  taught 
to  have  an  eye  to  the  future  he  may  be  permitted  to  manage  his 
own  diet  to  a  very  large  extent.  As  has  been  w'ell  said,  "A  man 
after  forty  is  either  a  fool  or  his  own  physician. ' ' 

To  begin  with,  in  every  case  forbid  all  rich,  fancy,  and  indigestible 
dishes,  as  well  as  all  foods  known  to  disagree  with  the  patient.     All 


636  DIET  I^  DISEASE 

rich  sauces  and  all  poorly  prepared  foods  should  be  warned  against. 

The  aim  in  the  gouty  is  to  give  sufficient  protein  food,  but  the 
exact  amount  that  produces  the  best  results  will  doubtless  always  be 
an  indiddual  question,  although  eventually  studies  in  gout  metab- 
olism may  throw  much  light  on  this  point.  The  minimum,  naturally, 
should  not  be  below  that  determined  by  Chittenden,  and  perhaps 
somewhat  above  this  will  be  found  to  be  best,  that  is,  about  70  gm. 
of  protein  daily  for  an  average-sized  individual.  This  should  be 
given  largely  as  eggs  and  egg  dishes,  milk  and  milk  dishes,  and 
oheeses,  together  with  what  is  derived  from  the  vegetable  part  of  the 
diet.  The  purin  foods  should  be  allowed  as  suggested  above.  It 
has  been  suggested  that,  as  uric  acid  retention  occurs  more  at  night, 
the  purin  food  is  best  given  in  the  morning.  Man}-  cases  may  be 
allowed  meat  once  a  day  and  fish  once  a  day,  preferably  not  at  the 
same  meal.  The  white  varieties  of  fish  seem  to  be  best  according 
to  clinical  experiences.  Fresh  beef  or  mutton  or  poultry  are.  as  a  rule, 
digested  better,  and  twice  cooked  and  salt  meats  as  well  as  salt  fish 
are  usually  forbidden,  but  there  may  be  exceptions  to  this. 

The  tolerance  for  fats  varies.  As  a  rule,  a  certain  amount  of  but- 
ter, cream,  olive  oil,  and  crisp  bacon  may  be  allowed.  If  the  fats 
cause  indigestion  the  amounts  should  be  lessened. 

Sugars  and  sweets,  as  a  rule,  do  not  agree.  Individual  experience 
is  the  best  guide;  as  a  rule  the  minimum  should  be  allowed.  Honey 
or  stewed  fruits  (compotes)  are  generally  included  in  German 
dietaries. 

Starchy  foods,  as  breadstuffs,  cereals,  and  potatoes,  may  be  allowed 
according  to  the  patient's  ability  to  digest  them  without  fermentation 
and  flatulence.  This  is  always  an  individual  question  and  often  a 
difficult  one  to  decide.  Many  gouty  patients  are  obese,  and  the 
starches  in  such  should  be  reduced  to  a  minimum.  Oatmeal  is  not 
advisable  on  account  of  the  high  purin  content.  Vegetables  may  be 
given  if  well  digested.  It  should  be  remembered  that  peas,  beans, 
lentils,  mushrooms,  spinach,  and  peppers  all  contain  considerable  pu- 
rin nitrogen.  These  should  be  allowed  in  moderation,  sparingly,  or 
not  at  all,  according  to  the  exigencies  of  the  cases.  Carrots,  cauli- 
flower, artichokes,  salsify,  turnips,  onions,  greens,  cabbage,  beets,  etc., 
may  be  allowed.  Wlien  sugar  disagrees,  carrots  and  beets  may  be  re- 
stricted. Asparagus,  rhubarb,  tomatoes,  and  sorrel  are  questionable 
and  certainly  do  not  agree  with  some  patients,  possibly  on  account  of 
acids. 

As  in  all  other  things  pertaining  to  the  gouty  diet,  there  is  a  great 
diversity  of  opinion  concerning  fruit.  It  depends  largely  on  the  indi-  . 
vidual  patient.  Grapes  and  oranges  are,  as  a  rule,  best  borne.  Baked 
apples  and  stewed  fruit  come  next.  Some  advise  strawberries  on 
account  of  the  potassium  contained,  others  forbid  them.  In  some 
patients  they  cause  considerable  disturbance.     If  one  wishes  to  try 


DISEASES  IN  WHICH  DIET  /*S'  .1    I'h'IMARV  FACTOR 


637 


potassium-containing  fruits,  a  list  will  be  found  under  the  heading  of 
Salts. 

If  the  patient  shows  signs  of  any  gouty  disturbance  a  milk  diet  for  a 
few  days  will  be  found  of  great  service. 

Care  should  be  taken  not  to  starve  the  patient.  A  sufficient  amount 
of  well-prepared  food  should  be  taken  each  day.  There  is  no  disease 
concerning  which  there  is  as  much  difference  of  opinion  concerning 
diet,  and  the  attempts  to  follow  the  directions  of  the  older  writers  is 
apt  to  lead  to  starving  the  patient  and  unnecessary  restriction. 

100  Grams  contain  in  terms  of  "Purin-nitrogen." 


More  than   .1   gni. 


.03-.05  gm. 


.01-03  gm. 


None  or  less 
than  .01. 


Thymus 

(.33) 

Beef  kidney 

Pork 

Bacon 

All  fruits 

Calves' 

liver 

Squab 

Veal 

Oysters 

Cereals 

(.11) 

Calves'  tongue 

Mutton 

Crabs 

Milk 

Ancho\'y  (.18) 

Herring 

Beef 

Lobster 

Cheese             None 

Sardines 

;  in  oil 

Trout 

Roe 

Sausage 

Bread 

(.14) 

Salmon 

Haddock 

Peas 

Eggs 

Percli 

Chicken 

Asparagus 

Caviar 

Pike 

Calves'  brain 

Mushrooms 

Vegetables    not 

Lentils 

Codfish 

Turnips 

in    the    other 

Spinach 

Cabbage 

lists. 

1  part  of  purin-base  nitrogen,  theoretically,  can  give  rise  to  .3  parts  of  uric 
acid.  Practically,  60  per  cent,  of  the  ingested  purins  appear  in  the  urine  as  uric 
acid. 

Cort'ee,  tea  and  cocoa  contain  xanthin  bases,  but  these  are  not  excreted  in  the 
form  of  uric  acid,  hence  need  not  be  forbidden. 

Such  vegetables  as  radishes,  water-cress,  paprika,  garlic,  etc.,  are  best  omitted, 
not  because  they  favor  uric  acid  formation,  but  because  tliey  are  renal  irritants. 
The  same  is  true  of  mustard-relishes,  catsup,  and  tlie  like. 

Alcohol  in  all  forms,  is  best  avoided;  it  influences  purin  metabolism  in  ways 
unfavorable  to  the  gouty  individual,  favors  vascular  sclerosis,  etc. 

Avoid  meat  extracts — bouillons,  dish  gravies,  and  tlie  outer  crusts  of  roasts. 

The  evening  meal  should  be  frugal  and  bland. 

The  best  drink  is  undoubtedly,  water ;   carbonated  waters  are  permitted. 

Lithia  water  is  not  a  uric  acid  solvent. 

Saline  Springs. — Visits  to  mineral  springs  and  the  taking  of 
mineral  waters  at  home  often  exert  a  happy  influence  over  some  cases 
of  gout.  The  nature  of  the  water  seems  to  be  of  secondary  import- 
ance, for  it  seems  to  be  the  water,  and  not  the  salts  contained  in  it, 
that  is  helpful.  The  relation  of  the  various  salts  to  gout  is  not  thor- 
oughly understood. 

The  following  points,  regarding  the  choice  of  a  spring,  are  given 
by  various  authors : 

For  acute  and  periodic  attacks  of  gout :  Assmannshausen,  Ems, 
Neuenahr,  Royat,  or  Vichy. 

For  the  plethoric  and  robust,  where  there  is  a  strong  hereditary 
predisposition  or  where  there  is  stomach,  intestinal,  liver,  or  kidney 
disease :     Carlsbad  or  Marienbad. 

For  chronic  and  debilitated  cases:  Kissingen,  Homburg,  Baden- 
Baden,  Bourbonne-les-Bains,  Harrogate,  or  Weisbaden. 


638  DIET  IN  DISEASE 

For  long-continued  domestic  use  in  mild  cases :  Gieshiibel,  Salvat- 
orquelle,  or  Vals. 

Among  the  American  springs  may  be  mentioned:  Hot  Springs, 
Va. ;  Hot  Springs,  Ark. ;  Hot  Springs,  N.  C. ;  Mt.  Clemens,  Mich. ; 
Las  Vegas,  X.  M, ;  Sweet  Springs,  Pa. ;  Capon  Springs,  W.  Va. ; 
Glenwood  Springs,  Colo. ;  Coronado  Springs,  Colo. ;  Saratoga  Springs, 
N.  Y. ;  White  Sulphur  Springs,  W.  Va. ;  Bedford,  Va. 

Osier  recommends  the  following:  American — Saratoga,  Bedford, 
and  White  Sulphur.  English— Buxton  and  Bath.  French — Aix-les- 
Bains  and  Contrexeville.  German — Carlsbad,  Wildbad,  and  Hom- 
burg. 

Alcohol  and  Gout. — There  is  probably  but  little  doubt  as  to  the 
injurious  effect  of  alcohol  in  gouty  subjects,  and  it  serves  not  onh^  as  a 
predisposing  factor,  but  as  an  exciting  cause.  If  the  patient  has 
never  used  alcohol  or  used  it  but  sparingly,  and  if  it  is  not  needed 
especially  as  a  stimulant,  it  should  be  excluded  entirely  from  the  diet. 
On  the  other  hand,  if  the  patient  has  been  habituated  to  the  use  of 
alcohol,  its  withdrawal  is  often  followed  by  serious  consequences. 
This  is  most  true  in  those  who  are  weak,  whose  circulation  is  poor,  or 
whose  stomach  demands  an  alcoholic  stimulant  before  it  Ijegins  work. 
Sydenham  said:  "The  old  saw  is  that  if  you  drink  wine  you  will 
have  the  gout,  if  you  do  not,  the  gout  will  have  you" — in  other  words, 
"while  it  may  be  good  for  the  patient,  it  is  bad  for  the  disease.'"' 

Alcohol  is  coutraindicated  in  acute  gout  except  in  the  weak  and 
aged.  In  subacute  gout  and  in  chronic  gout  alcohol  should  be 
avoided  wherever  possible.  When  its  use  is  necessary,  the  best  form 
of  alcohol  for  these  patients  is  undoubtedly^  well-matured  pure  whisky 
sufficiently  diluted  with  water.  The  daih^  allowance  should  be  placed 
as  low  as  possible — two  ounces  or  double  that  quantity  in  some  cases 
should  ordinarily  suince.  Good  old  brandy  or  gin  may  be  substituted 
for  the  sake  of  variety.  Wines  and  malt  liquors  are  best  avoided, 
but  curious  idiosyncrasies  in  regard  to  them  exist.  The  choice  of  a 
wine  for  the  gouty  is  a  matter  of  personal  taste  and  experience.  All 
very  sweet  or  acid  wines  are  injurious.  Ewart  gives  the  following 
rules  for  choosing  wines,  and  says  that  the  best  are  those  with  a 
"moderate  percentage  of  alcohol  and  of  ether;  least  possible  degree 
of  acidity;  freedom  from  unfermented  sugar,  as  far  as  that  is  con- 
sistent with  a  natural  unadulterated  condition;  freedom  from  tannin; 
genuineness  as  to  vintage,  or  at  least  to  derivation ;  mixed  wines  do 
the  most  harm ;  and  lastly,  matured  age. ' ' 

Good  claret  or  a  dry  Moselle  is  perhaps  the  best,  while  champagne 
is  perhaps  the  most  injurious,  wine  for  the  gouty.  This  last,  however, 
as  most  every  variety  of  wine,  has  some  enthusiastic  advocates. 

Tea  and  coffee  may  be  allowed,  but  it  is  desirable  that  they  be 
given  unsweetened  and  not  too  strong.     If,  however,  sweetening  is 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR  639 

thought  advisable,  as  it  usually  is,  tablets  of  saccharin  may  be  used 
in  place  of  sugar. 

The  Special  diseases  of  the  gouty  requiring  particular  attention 
are  the  following : 

Gouty  Glycosuria  and  Diabetes. — While  a  restricted  diet  is  not  de- 
sirable in  these  eases,  large  quantities  of  meat  and  heavy  breads  are 
generally  productive  of  more  harm  than  good.  Very  often,  if  the 
gouty  condition  receives  proper  attention,  the  glycosuria  will  be  les- 
sened or  may  even  disappear  entirely.  A  moderate  quantity  of  meat 
and  fish,  with  well-toasted  bread,  brown  bread,  pulled  bread,  rice, 
macaroni,  and  the  like,  in  moderation  are  to  be  allowed,  together  with 
milk,  cream,  and  fatty  foods.  If  symptoms  are  present,  a  milk  diet 
for  a  short  period  will  usually  be  found  beneficial.  It  is  often  well 
in  these  cases,  even  when  the  symptoms  are  not  urgent,  to  give  an 
occasional  diet  of  milk. 

Gouty  Albuminuria. — In  this  condition  the  most  suitable  diet  is 
one  containing  but  a  moderate  quantity  of  meat  of  the  least  irritating 
character,  such  as  the  white  meat  of  chicken,  steak,  chops  and  roasts. 
The  meat  should  be  lean.  The  white  meat  of  boiled  fish  of  the 
lighter  varieties  and  the  more  easily  digestible  vegetables  may  also 
be  permitted.  Whenever  the  amount  of  albumin  in  the  urine  is  very 
large,  or  when  there  are  symptoms  of  nephritis,  a  milk  diet  may  be 
given  for  a  few  days  or  a  week  at  a  time. 

Acid  Gouty  Dyspepsia. — This  is  one  of  the  most  serious  and  most 
troublesome  of  the  gouty  affections.  Many  cases  require  a  milk  diet, 
and  it  may  be  necessary  to  peptonize  the  milk  partially  or  completely. 
Peptogenic  milk  powder  or  one  of  the  infant  foods  may  also  be  used. 
Malted  milk,  albuminized  foods,  or  the  malted  foods  may  be  utilized. 

In  the  less  severe  cases,  lean  meat  and  fish  may  be  allowed  in  small 
quantities.  Well-prepared  vegetables  may  be  given  sparingly,  while 
starches  and  fats  are  usually  best  avoided.  The  management  of  these 
cases  is  essentially  the  same  as  if  gout  were  not  present. 

Gouty  Obesity. — The  management  here  is  similar  to  that  in  other 
conditions.  Ebstein  regards  obesity  in  the  gouty  as  an  unfavorable 
symptom,  and  recommends  meat  and  fat  and  reduces  the  carbohydrate 
food  to  the  smallest  possible  amount.  His  theory  is  that  the  fats 
protect  the  metabolism  of  the  proteins  to  a  smaller  degree  than  do 
the  starches  and  sugars.  Sugar  should  be  reduced,  and  only  as  little 
liquid  as  it  is  possible  to  get  along  with  should  be  allowed.  Some 
authors  recommend  alcohol  in  small  quantities.  Duckworth  gives  a 
small  amount  of  red  Bordeaux  wine  mixed  with  a  little  water.  Open- 
air  life — horseback  riding  or  other  outdoor  exercise— is  advisable. 
An  occasional  visit  to  some  mineral  spring  as  suggested  above  is  often 
beneficial. 


640  DIET  IN  DISEASE 

RHEUMATOID  ARTHRITIS   (ARTHRITIS  DEFORMANS) 

In  this  disease  the  diagnosis  should  be  carefully  made,  as  it  is 
important  that  the  patient  receive  a  supporting  diet,  and  not  the 
restricted  diet  of  the  rheumatic  and  gouty. 

Diet  apparently  plays  no  part  in  the  etiology  of  the  disease.  As 
in  any  chronic  disease  interfering  with  active  exercise  the  digestion 
is  apt  to  be  below  normal,  and  care  must  be  taken  that  the  food  be 
digestible  and  taken  in  sufficiently  small  quantities.  Heavy  foods 
and  indigestible  articles  should  be  avoided,  as  the  patient  must  needs 
lead  a  sedentary  life ;  as  a  result  of  the  latter  constipation  is  apt  to 
exist  and  must  be  corrected. 

Garrod  recommends  a  considerable  quantity  of  meat  to  be  taken  in 
a  well-mixed  diet.  Alcohol  has  apparently  no  influence  on  the  dis- 
ease, and  either  spirituous  or  malt  liquors  may  be  used,  if  desirable, 
to  support  the  patient's  strength.  The  chief  dietetic  indication  is 
the  avoidance  of  anything  that  will  cause  indigestion. 

Pemberton  has  made  a  stud.y  of  nearly  forty  cases  with  directly 
the  opposite  conclusion  to  the  above  statements.  He  advises  a  diet  of 
low  value,  reducing  the  proteins  and  either  eliminating  the  carbo- 
hydrates entirely  or  reducing  them  to  a  minimum.  He  believes  that 
the  carbohydrates  play  an  important  part  in  the  etiology  of  the 
disease.  His  ideas  are  worthy  of  careful  consideration,  especially  as 
the  present  methods  of  dealing  with  the  disease  are  so  unsatisfactory. 

Bovaird  has  suggested  a  diet  low  in  calcium. 

OBESITY 

Obesity  is  one  of  the  conditions  for  which  the  physician  is  fre- 
quently^ asked  to  prescribe  a  diet  cure.  He  should,  therefore,  be 
thoroughly  informed  concerning  its  causation,  its  management,  and 
the  reasons  for  and  against  reducing  any  given  case. 

There  is  probably  no  condition  that  has  been  more  widely  discussed 
by  laymen  of  both  ancient  and  modern  times  than  obesity,  for  no  dis- 
ease is  more  thoroughly  associated  in  the  lay  mind  with  its  proper 
causes  and  its  relations  to  diet  than  this  "oily  dropsy,"  as  Byron 
calls  it.  Among  the  better  known  examples  that  have  been  mentioned 
in  fiction  are  Silenus  and  his  son  Bacchus,  as  well  as  the  more  modern 
Falstafl^.  Many  historic  characters  were  hampered  by  obesity.  Epa- 
minondas,  the  Greek  senator,  the  Minstrel  of  Megara,  with  a  three- 
yard  girdle,  and  Eglon,  king  of  Moab,  are  familiar  examples.  Ches- 
terfield said :  ' '  Obesity  and  stupidity  are  such  constant  companions 
that  they  are  considered  sj^nonymous. "  There  have,  however,  been 
numerous  examples  of  men  of  extraordinary^  mental  ability  and  even 
activity  who  were  obese,  but  we  are  all  inclined  to  remember  the 
fat  boy  in  Dickens'  Pickwick  Papers,  who  did  nothing  but  eat 
and  sleep. 

The  accumulation  of  fat  is  associated  with  increasing  years,  but 


I 


DISEASES  /.V    WHICH  DIET  IS  A  PRIMARY  FACTOR  641 

it  is  by  no  means  confined  to  either  old  or  middle  age,  as  is  exem- 
plified in  the  fat  children  familiar  to  all;  extreme  obesity  may  be  a 
plague  even  of  infants.  Chambers  is  said  to  have  reported  a  case 
that  he  saw  on  exhibition  at  Manchester — a  baby  that  weighed  90 
pounds  at  six  months.  Numerous  cases  are  on  record  where  babies  of 
this  age  weighed  as  much  as  forty  pounds. 

From  Hippocrates'  time  down  to  the  present  day  directions  have 
been  given  for  the  cure  of  this  troublesome  condition.  Shakespeare 
gave  the  essentials  of  the  treatment  and  stated  the  dangers  of  obesity 
when  he  wrote : 

"Make  less  thy  body  hence,  and  more  thy  grace. 
Leave  gormandizing;   know  the  grave  doth  gape 
For  thee  thrice  wider  than  for  other  men." 

With  Justus  von  Liebig's  work  came  a  better  understanding  of  the 
formation  of  fat  in  the  body,  and  while  there  are  still  very  diverse 
opinions  on  the  subject,  the  condition  is,  in  the  main,  fairly  well  un- 
derstood. In  1850  Chambers  warned  against  fat,  bread,  and  potatoes. 
In  1863  Mr,  Louis  Banting,  an  Englishman,  published  a  letter  giving 
an  account  of  a  method  of  diet  that  he  had  employed  on  himself  with 
great  benefit.  This  method  was  that  of  Harvey,  who  was  Banting's 
physician.  Harvey's  name  was  withheld  at  the  time,  and  as  a  result 
the  name  of  Banting  has  become  associated  with  reduction  cures  and 
obesity.  Ebstein  published  his  work  in  1882,  and  there  have  been 
numerous  authors  and  physicians  who  have  formulated  methods  for, 
or  made  suggestions  concerning,  the  treatment  of  obesity.  Oertel 
was  the  first  to  point  out  that  there  was  a  close  relation  between 
obesity  and  weak  heart,  and  he  made  abundant  contributions  to  the 
literature  on  the  correct  management  of  these  diseases. 

The  causes  of  obesity  are  so  well  known  as  to  require  only  passing 
mention.  About  50  per  cent,  owe  their  primary  origin  to  hereditary 
causes.  Women  are  more  frequently  affected  than  men.  With  the 
advance  of  years,  in  some  there  is  a  tendency  to  accumulate  fat. 
Overeating  and  over-drinking  have  been  named  as  causative  factors, 
especially  when  combined  with  a  quiet,  sedentary  life. 

The  fats  and  the  carbohydrates  are  the  principal  elements  in  the 
diet  that  are  apt  to  be  converted  into  fat ;  but  proteins  also,  if  the 
supply  exceeds  the  demand  and  assimilation  is  active,  will  be  con- 
verted into  body-fat  and  stored  up  in  the  subcutaneous  tissues.  The 
liver  and  heart  are  also  converted  into  storehouses  for  fat,  and  later 
there  may  be  a  fatty  degeneration  of  both  organs,  as  well  as  of  the 
coats  of  the  arteries. 

The  dangers  accompanying  the  excessive  accumulation  of  fat  are 
manifold,  and  include  a  large  number  of  diseases  that  may  be  influ- 
enced by  it  either  directly  or  indirectly.  These  will  be  discussed 
when  the  indications  for  reducing  the  weight  of  patients  are  con- 
41 


642  DIET  IN  DISEASE 

sidered.  Weak  heart,  anemia,  gout,  and  diabetes  are  among  the 
most  frequent  diseases  associated  with  obesity. 

Treatment. — It  is  necessary,  in  attempting  to  treat  this  condition 
to  distinguish  between  the  cases  that  are  plethoric  and  those  that  are 
anemic.  One  should,  moreover,  consider  each  case  carefully,  before 
reduction  is  decided  upon.  The  condition  of  the  blood,  of  the  heart, 
and  of  the  liver,  and  the  rate  of  increase  in  the  patient's  weight, 
should  all  be  considered. 

The  general  appearance  of  the  patient — whether  the  symmetry  of 
the  body  is  preserved  or  whether  it  is  distorted  by  fat-deposits — is 
also  to  be  studied.  More  important  still  is  the  condition  of  the  func- 
tions of  the  body  and  the  state  of  the  nervous  system.  Of  especial 
value  is  it  to  learn  the  amount  of  disturbance  of  respiration  and  of 
circulation. 

The  age  of  the  patient  is  a  factor  of  paramount  importance.  In 
persons  under  twenty  reduction  cures  should  not,  as  a  rule,  be 
used,  but  the  diet  should  be  so  arranged  that  there  will  be  no  in- 
crease in  the  amount  of  fat  deposited.  When  the  weight  is  to  be 
reduced,  it  should  be  done  very  gradually,  and  when  from  tive  to 
fifteen  pounds  have  been  lost,  a  season  of  rest  should  follow.  The 
period  of  restricted  diet  should  not  exceed  four  or  five  weeks. 

The  reduction  of  patients  from  twenty  to  fifty  years  or  older  may 
be  undertaken  if  other  circumstances  warrant  it;  this  will  be  con- 
sidered later. 

During  and  even  a  little  preceding  the  period  of  senescence  reduc- 
tion should  not  be  permitted.  The  physical  condition  of  the  patient, 
rather  than  the  number  of  years,  should  be  the  guide,  for  some 
persons  grow  old  earlier  than  do  others.  The  condition  of  the  ar- 
teries is  a  good  guide  to  senility,  based  on  the  dictum  that  a  man  is 
as  old  as  his  arteries.  In  persons  in  the  decline  of  life  reduction 
generally  hastens  very  materially  the  breaking-down  of  the  bodily 
forces. 

The  following  suggestions  concerning  the  various  grades  of  the 
disease  and  their  fitness  for  reduction  cures  will  be  found  useful : 

Advanced  cases — and  they  may  be  judged  from  their  general  ap- 
pearance and  condition  of  health — are,  as  a  rule,  fit  subjects  for 
reduction. 

In  those  who  have  been  fat  all  their  life  or  who  have  been  fat  for 
several  decades,  and  who  are  approaching  old  age,  a  reduction  cure 
should  not  be  undertaken. 

Average  cases,  where  the  weight  is  from  thirty  to  fifty  pounds 
above  the  average  for  their  age,  sex,  and  condition  in  life,  should 
not  be  reduced  if  they  are  aged.  If  the  extra  weight  is  well  borne, 
they  do  not  need  it,  and  the  diet  should  be  so  arranged  as  to  prevent 
any  further  increase.  If  there  is  any  reason  to  fear  disease,  they 
should  be  reduced.     If  the  patient  takes  a  great  deal  of  exercise,- uses 


DISEASES  IX  WHICH  DIET  IS  A  PRIMARY  FACTOR  643 

any  quantity  of  alcohol,  or  is  given  to  excesses  in  eating-,  or,  in  fact, 
anything,  he  should  be  reduced,  for  the  chances  are  that  he  will 
accumulate  fat  as  time  goes  on  or  will  become  the  subject  of  disease 
which  his  obesity  will  aggravate.  Kapid  reduction  in  these  cases  is 
bad  as  a  rule,  and  it  should  be  slow  and  systematic. 

Slight  degrees  of  obesity,  where  the  body  weight  is  from  ten  to 
thirty  pounds  over  the  average,  do  not  need  reduction,  but  only  a 
careful  regulation  of  the  diet  and  mode  of  living,  so  as  to  prevent  any 
further  deposits  of  fat. 

The  question  of  reducing  some  of  these  patients  must  be  considered, 
for  while  they  unquestionably  do  perfectly  well  on  a  limitation  of 
their  increase  in  weight,  still  the  question  of  personal  appearance  is 
an  all-important  factor  with  many  women.  It  is  more  often  the  ease 
with  those  slightly  above  the  average  than  for  those  that  are  very 
obese,  as  the  latter  have  become  accustomed  to  their  fat  and  are 
usually  resigned  to  it.  If  these  patients  are  not  reduced  the  neces- 
sary few  pounds,  they  will  go  to  one  physician  after  another  until 
they  find  some  one  who  will — generally  a  quack  who  may  do  more 
harm  than  good  by  his  methods  and  advice.  "When  the  personal 
appearance  can  be  used  as  an  argument  for  the  regulation  of  the  diet 
and  the  manner  of  living,  the  phj^sician  has  a  hold  upon  the  patient 
that  he  can  scarcely  get  by  any  other  means,  and  he  may  often  prevent 
an  accumulation  of  a  troublesome  amount  of  fat  in  after  years  by  the 
careful  instruction  of  the  patient  in  the  art  of  living  as  it  must 
be  practised  by  that  particular  individual.  As  Ebstein  puts  it,  ' '  Cor- 
pulence can  only  be  permanently  cured  by  a  permanent  change  of 
life  and  diet,  regulated  by  physiologic  principles. ' ' 

There  are  certain  objections  that  may  be  raised  to  reduction  in 
women.  The  loss  of  the  abdominal  fat  may  lead  to  constipation,  to 
hernia,  to  gastroptosis,  to  dislocation  of  the  kidney,  and  even  of  the 
uterus.  Von  Noorden  states  that  these  patients  may  develop  gall- 
stone colic,  which  probably  results  from  the  pressure  of  the  clothing 
on  the  liver,  causing  interference  with  the  flow  of  bile,  and  conse- 
quently favors  the  formation  of  gall-stones.  So  long  as  the  patients 
are  obese  the  pressure  exerted  by  the  clothing  is  usually  trifling  and 
does  not  fall  directly  on  the  liver.  These  objections  to  reduction 
cures  in  women  are  more  marked  in  mild  than  in  the  more  advanced 
cases. 

A  much  discussed  point  is  whether  it  is  possible  to  reduce  any 
special  part  of  the  body  more  rapidly  than  the  remaining  parts.  This 
is  a  method  often  sought  by  women  who  have  borne  several  children 
and  who  have  large  deposits  of  fat  in  the  abdominal  walls,  causing 
an  unsightly  prominence  of  the  abdomen.  If  the  fat  is  reduced 
slowly,  every  part  of  the  body,  including  usually  the  abdomen  as 
well,  will  be  reduced  simultaneously.  If  it  is  reduced  rapidl5^  it 
seems  to  be  removed  principally  from  certain  parts  of  the  body,  as  the 


644  DIET  7.Y  DISEASE 

neck,  breasts,  arms,  and  calves  of  the  legs.  Certain  advocates  of  mas- 
sage claim  that  the  massage  of  the  parts  will  cause  a  more  rapid 
reduction.  Von  Noorden  had  one  arm  of  an  obese  patient  massaged 
for  six  weeks.  At  the  end  of  that  time  the  arm  that  had  been  mas- 
saged had  increased  one  and  one-half  centimeters  in  circumference, 
whereas  the  arm  that  had  not  been  massaged  remained  the  same. 

Massage  of  the  abdomen  during  a  reduction  cure  may  exert  a 
beneficial  effect  by  relieving  the  constipation,  which  is  apt  to  be 
troublesome.  Exercise  is  still  more  potent,  particularly  for  reducing 
the  abdomen.  This  is  accomplished  by  standing  erect  and  then  bend- 
ing forward  in  an  effort  to  touch  the  toes  with  the  tips  of  the  fingers. 
Too  much  should  not  be  expected  from  this,  even  when  persisted  in 
faithfully. 

When  disease  exists  together  with  obesity,  a  reduction  cure  is  often 
indicated,  and  it  is  frequently  the  most  important  part  of  the  treat- 
ment, although  it  is  one  that  is  too  often  overlooked.  In  such  cases 
a  reduction  of  the  amount  of  fat  may  not  only  render  the  patient  more 
comfortable,  but  in  many  cases  may  be  the  direct  means  of  prolong- 
ing the  patient's  life  and  period  of  usefulness.  In  these  cases  reduc- 
tion is  not  to  be  regarded  as  a  weakening  process,  the  reverse  being 
true — the  patients  usually  grow  stronger  as  their  weight  grows  less. 
It  must  be  borne  in  mind,  however,  that  each  case  is  to  be  studied 
carefully  and  treated  individually,  for  no  general  rule  can  be  made 
to  apply  to  every  case  that  comes  under  the  physician's  care.  This 
applies  not  only  as  to  the  question  of  reduction,  but  also  to  the 
manner  in  which  this  is  to  be  accomplished. 

Diseases  Combined  with  Obesity. — Diseases  of  the  Circulatory 
System. — To  Oertel  belongs  the  credit  of  pointing  out  the  great 
benefits  to  be  derived  from  a  rational  method  of  treating  affections 
of  the  heart  when  combined  with  obesity.  Benefit  follows  not  only 
in  patients  with  valvular  lesions,  but  in  those  suffering  from  other 
diseases  as  well.  Among  these  conditions  may  be  mentioned  arter- 
iosclerosis, myocarditis,  degeneration  of  the  heart  muscle,  the  so- 
called  fatty  heart,  aneurysm  of  the  aorta,  and  those  diseases  of  the 
chest  or  respiratory  organs  that  interfere  with  the  circulation. 

The  reduction  of  the  body  weight  in  these  cases,  it  should  be  under- 
stood, does  not  alter  the  character  of  the  lesion  itself,  but  it  lessens 
greatly  the  work  of  the  heart,  and  permits  of  more  complete  oxidation 
of  the  blood.  It  is  of  especial  value  in  those  cases  where  the  existence 
of  the  lesion  itself  is  not  incompatible  with  the  life  of  the  patient  so 
long  as  he  is  kept  in  reasonablj'  good  condition.  If  reduction  is 
undertaken  before  there  is  any  failure  of  compensation,  the  results 
are,  as  a  rule,  very  gratifying.  If  compensation  is  on  the  verge  of 
rupture,  or  if  it  has  actually  begun,  it  may  often  be  checked  to  a 
remarkable  degree  and  sometimes  averted  altogether.  Reduction  may 
work  wonders  even  in  what  at  first  seem  to  be  very  severe  cases.     In 


DISEASES  ly  WHICH  DIET  IS  A  PRIMARY  FACTOR  645 

the  hopeless  cases  it  is  useless  to  attempt  it.  One  should  not,  how- 
ever, be  too  hasty  in  deciding  that  a  case  is  hopeless,  for  even  very 
serious  eases  may  be  relieved. 

The  suggestions  for  treatment  made  by  Oertel  are  most  useful,  and 
will  be  given  further  on.  For  patients  where  compensation  is  perfect, 
but  whose  bodies  are  obese  to  a  degree  that  seems  to  the  physician  to 
indicate  danger,  a  rapid  reduction  cure  may  be  instituted.  Where 
there  is  beginning  failure  of  compensation,  Groedel,  of  Nauheim,  von 
Noorden,  and  others  recommend  large  doses  of  digitalis,  to  be  fol- 
lowed by  a  somewhat  rapid  reduction.  This  may  be  effected  by  any 
method,  but,  according  to  the  authors  just  named,  those  methods 
involving  the  use  of  salines  should  be  avoided.  The  amount  of  fluid, 
as  well  as  food,  must  be  limited.  The  reduction  is  best  undertaken  at 
a  sanitarium.  For  the  first  few  weeks  four  or  five  pounds  a  week 
may  be  removed,  and  after  that  about  that  many  a  month. 

The  worst  cases  are  those  in  which  edema  occurs  together  with 
obesity.  In  these  cases,  as  a  rule,  not  much  is  to  be  hoped  for,  and  a 
reduction  cure  in  the  ordinary  sense  of  the  word  should  not  be  un- 
dertaken. These  patients  do  not  generally  have  any  great  desire  for 
food,  and  hence  the  amount  of  liquid  consumed  should  be  the  point  of 
especial  consideration.  The  heart  should  be  stimulated,  and  later, 
if  possible,  exercises  should  be  begun.  Digitalis  is,  of  course,  of  the 
greatest  use  in  these  cases.  The  food  need  not,  as  a  rule,  be  limited, 
unless,  as  improvement  sets  in,  fat  be  deposited ;  this  is  not,  however, 
apt  to  be  the  case.     (See  also  Karell  Diet.) 

Diseases  of  the  Respiratory  System.— These  are  to  be  considered 
principally  in  their  relation  to  the  circulation,  and  what  has  been 
said  of  heart  diseases  applies  with  equal  truth  to  these.  The  most  fre- 
quent respiratory  disturbances  are  adherent  pleurisy  and  emphy- 
sema. A  kyphosis,  by  compressing  the  chest  space,  may  also  prove 
troublesome.  A  reduction  of  the  body  weight  often  brings  about  a 
marked  improvement  in  these  cases. 

Bronchitis  in  fat,  and  especially  in  elderly,  patients  is  apt  to  be 
very  troublesome.  In  many  patients  a  very  resistant  bronchitis, 
which  does  not  yield  either  to  drugs  or  to  climatic  treatment,  occurs 
every  winter.  In  these  cases  a  reduction  of  the  body  weight,  by 
allowing  the  patient  to  breathe  deeply  and  with  ease,  will  often  be 
of  more  assistance  in  effecting  a  cure  than  all  other  measures  com- 
bined. 

Chronic  and  interstitial  nephritis  is  also  a  disease  in  which  the 
patient  must  either  be  reduced  or  at  least  the  amount  of  food  and 
drink  be  so  limited  as  to  prevent  any  further  increase  in  weight. 
(See  the  section  on  Diseases  of  the  Kidney.) 

In  many  diseases  that  affect  the  legs,  such  as  hemiplegias,  cord 
disease,  and  neuritis,  as  well  as  the  many  surgical  disorders  affecting 
the  feet  or  legs,  a  reduction  in  the  body  weight  will  often  permit  the 


646  DIET  IX  DISEASE 

patient  to  go  about  with  considerable  ease,  whereas  if  he  is  allowed 
to  accumulate  fat  he  may  ultimately  become  practically  helpless. 
The  same  may  be  said  of  chronic  articular  rheumatism,  of  arthritis 
deformans,  or  of  osteo-arthritis  affecting-  the  lower  extremities. 

Obesity  and  gout  form  a  combination  that  presents  unusual  diffi- 
culties in  the  selection  of  a  proper  diet.  If  the  patients  subsist  on 
an  anti-gout  diet,  they  gain  in  weight,  and  if  they  adhere  to  a  diet 
that  aims  to  avoid  gain  in  weight,  they  are  apt  to  contract  gout. 
(The  reader  is  referred  to  the  section  on  Gout  for  further  information 
on  this  point.)  One  must  choose  between  two  evils  and  arrange  the 
diet  accordingly.  As  a  rule,  a  diet  of  lean  meat  with  an  abundance 
of  fresh  fruit  and  green  vegetables  is,  in  the  average  case,  the  best. 

There  are  many  nervous  diseases  not  included  among  those  that 
render  locomotion  difficult  that  are  frequently  either  benefited  or 
entirely  cured  by  a  reduction  in  body  weight  if  the  patient  has  been 
much  above  the  average.  ]\Iost  important  of  these  are  the  various 
neuralgias,  which  are  often  the  bane  of  fat  persons.  Sciatica  and 
occipital,  supra-orbital,  and  left-sided  brachial  neuralgia  are  among 
those  nervous  disorders  that,  according  to  von  Noorden,  may  be  most 
frequently  relieved. 

This  same  observer  has  pointed  out  another  condition  in  which 
gain  in  weight  should  be  limited — one  that  is  frequently  overlooked 
by  the  average  practitioner.  This  is  in  obesity  following  the  cures 
for  pulmonary  tuberculosis.  These  patients  frequently  take  on  large 
quantities  of  fat,  and  in  some  cases  the  very  fatness  they  strive  to 
acquire  may  be  the  means  of  their  undoing,  interfering,  as  it  may, 
with  exercise  and  with  breathing.  Fortunately  this  class  of  cases  is 
not  large.  If  they  continue  to  gain  in  weight  after  the  pulmonary 
disorder  has  been  cured,  or  if  the  weight  becomes  a  source  of  danger 
to  them,  the  patient's  diet  should  be  so  arranged  as  to  limit  the 
amount  of  fat  deposited. 

In  all  cases  the  patient  must  be  told  that  it  is  only  by  perseverance 
that  any  permanent  good  can  be  effected.  Little  is  to  be  gained  by  a 
few  weeks'  dieting  or  by  a  sojourn  for  a  few  weeks  at  a  watering  place 
if  the  diet  is  to  be  unrestricted  thereafter.  Many  patients  who  will 
not  persevere  in  the  diet  while  at  home  do  well  at  a  resort,  or,  better 
still,  at  a  sanitarium,  where,  in  addition  to  being  reduced  in  weight, 
they  learn  the  art  of  living  as  well.  In  others  it  is  better  to  prescribe 
short  courses  at  various  intervals.  These  may  be  of  four  or  five  weeks' 
duration,  and  after  the  patient  has  lost  from  five  to  fifteen  pounds,  he 
may  be  allowed  some  freedom  in  the  interval. 

Exercise  is  of  the  greatest  importance,  and  should  be  carried  out 
according  to  the  suggestions  made  by  Oertel.  Exercise  in  the  open 
air,  such  as  walking  either  on  level  ground  or  uphill,  as  suggested 
by  Oertel,  is  to  be  preferred  to  indoor  exercise  and  gymnasium  train- 
ing.    In  certain  towns  in  Germany,  Austria,  and  Switzerland,  as  well 


DISEASES  IX  M'HICH  DIET  IS  A  PRIMARY  FACTOR  647 

as  in  this  country,  what  are  known  as  "terrain  cures"  have  been 
established ;  in  these  the  paths  are  marked  according  to  distance  and 
as  to  the  grade.  The  patient  is  carefully  instructed  by  the  physician 
as  to  how  far  he  is  to  walk  and  on  what  grades.  Similar  walk^  may 
be  planned  by  a  physician  anywhere  if  the  country  is  of  such  a 
nature  as  to  permit  it.  The  amount  of  exercise  should  be  carefully 
regulated,  and  the  distance  to  be  walked,  rather  than  the  time  that  is 
to  be  spent  in  walking,  clearly  outlined. 

In  cases  with  weak  hearts  prognosis  is  of  especial  importance.  Ac- 
cording to  Oertel,  if  there  is  hydremia  or  circulatory  disturbance,  the 
prognosis  will  be  governed  by  the  difference  in  the  quantity  of  fluid 
taken  and  the  amount  of  urine  excreted.  For  two  days  the  patient 
should  take  as  much  fluid  as  he  has  been  accustomed  to,  and  the 
amount,  as  well  as  the  quantity,  of  urine  excreted,  noted.  For  two 
days  more  the  amount  of  fluid  should  be  reduced  to  from  700  to 
1000  c.c,  and  the  urine  should  again  be  measured.  If  with  the  re- 
duced amount  of  fluid  the  urine  is  equal  in  quantity  to,  or  larger 
than,  the  amount  of  liquid  ingested,  it  is  a  sign  that  the  heart  power 
is  not  excessively  weak  and  that  the  kidneys  are  in  fair  condition,  and 
a  favorable  prognosis  may  be  given,  providing  the  proper  regimen 
be  followed  out.  If  the  amount  of  urine  excreted  is  less  than  the 
quantity  of  water  ingested,  the  prognosis  is  unfavorable.  If  the 
urine  is  only  slightly  less,  this  may  be  regarded  as  an  actual  increase, 
as  from  18  to  20  per  cent,  of  that  taken,  as  well  as  the  amount  in  the 
solid  food,  is  given  off  with  respiration,  perspiration,  etc.  If  there  is 
arteriosclerosis,  fever,  or  diabetes,  the  prognosis  is  unfavorable. 

Prophylaxis  of  Obesity. — In  all  persons  with  a  hereditary  tend- 
ency to  obesity,  and  in  all  obese  persons  who  have  become  thin, 
prophylactic  measures  should  be  undertaken.  These  consist  in  an 
avoidance  of  fat-forming  foods,  and,  if  necessary,  in  a  careful  regula- 
tion of  the  diet  and  of  the  amount  of  exercise.  As  the  individual 
grows  older  and  the  danger  of  obesity  becomes  more  pronounced,  the 
diet  should  always  be  regulated  and  the  proper  amount  of  exercise 
insisted  upon. 

Diet  Cures. — In  the  past  there  have  been  a  great  many  different 
methods  of  dieting  for  purposes  of  reducing  the  weight.  These  have 
all  been  more  or  less  successful,  though  they  were  based  on  many 
different  conceptions  of  what  the  underlying  source  of  the  trouble 
was.  Very  often  reduction  cures  are  spoken  of  as  banting.  This 
method,  which  has  been  mentioned,  was  used  by  Banting,  who  re- 
duced his  weight  from  202  to  156  pounds,  a  loss  of  46  pounds.  The 
details  of  this  and  the  other  cures  mentioned  will  be  found  in  any  of 
the  first  four  editions  of  this  book.  The  Banting  diet  was  very 
severe  and  for  the  average  patient  needed  modification,  whereas  it  is 
entirely  unsuited  for  those  with  weak  digestion.  Following  its  use 
renal  colic  or  gall-stones  with  colic  are  very  apt  to  occur. 


648  DIET  ly  DISEASE 

Other  methods  that  have  been  popular  at  various  times  are  those 
devised  by  Schweniger,  whose  fame  was  greatly  enhanced  by  the  fact 
that  he  was  Bismarck's  physician.  He  insisted  upon  the  patient  not 
taking  any  fluid  with  the  meals  nor  for  two  hours  after;  Schleicher, 
who  advised  a  very  similar  diet,  whereas  Germain  See  used  a  diet 
in  which  the  fluid,  instead  of  being  diminished,  was  increased  in 
amount.  Weir  iNIitcheirs  method  consisted  of  putting  the  patient  on 
a  skim  milk  diet  or  a  skim  milk  diet  with  the  usual  food  and  in  a  week 
cut  out  everything  except  the  skim  milk.  The  quantity  of  this  is 
gradually  diminished  till  the  patient  loses  half  a  pound  of  weight 
each  day  or  less,  according  to  the  general  condition.  In  the  early  part 
of  the  treatment  the  patient  is  kept  in  bed  and  given  massage  and 
later  Swedish  movements.  (See  also  Karell  Diet.)  In  case  of  any 
feebleness  the  diet  is  increased  and  when  the  patient  is  reduced  to  the 
desired  point  a  careful  diet  is  outlined  to  prevent  the  recurrence. 
The  Salisbury  method  consists  of  using  only  meat  and  hot  water. 
The  water  may  be  flavored  with  lemon  juice  or  weak  tea,  if  desired. 
Yeo  suggested  a  dietary  much  on  the  order  of  that  used  at  the 
present  time.  The  Chambers  method  is  interesting  as  being  one  of 
the  earliest  systemic  modes  of  treatment  and  consisted  of  cutting  off 
the  fats  and  carbohydrate  food,  and  giving  lean  meats  and  green 
vegetables  and  salads  and  fruits. 

The  present  conception  of  obesity  is  that  it  may  be  divided  into 
two  groups ;  first,  the  so-called  exogenous  obesity,  in  which  the  metab- 
olism of  the  patient  is  normal,  but  in  which  the  patient  is  either 
taking  more  food  than  the  body  requires  or  is  taking  that  required  by 
a  person  in  active  life  and  living  a  life  of  laziness,  or  there  may  be 
a  combination  of  overnutrition  and  laziness.  The  second  group  is 
called  the  endogenous  or  constitutional  obesity  and  has  for  its  under- 
lying cause  a  slowing  of  the  nutrition,  so  that  the  food  is  not  metab- 
olized as  rapidly  as  in  normal  individuals.  These  cases  are  most 
commonly  due  to  hypothyroidism  or  to  disturbances  of  the  ovaries  or 
testicles,  sometimes  called  eunuchoid  obesity,  or  to  changes  in  the 
hypophysis  cerebri,  the  so  called  adiposis  genitalis,  or  the  obesity  of 
Frolich,  very  similar  to  the  eunuchoid  type.  Obesity  may  also  occur 
very  probably  from  over-action  of  the  pineal  gland  and  experimental 
obesity  due  to  pancreatic  changes  has  been  produced.  Not  infre- 
quently one  sees  a  combination  of  both  exogenous  and  endogenous 
obesity,  particularl}^  in  early  life. 


DISEAi<!ES  IN  WHICH  DIET  JS  A    PKIMAHY  FACTOR 


649 


To  determine  the  percentage  of  overweight  or  underweight  of  an  applicant,  se- 
lect the  normal  weight  for  his  age  and  heiglit  from  Table  No.  1.  Then  opposite 
the  normal  weight,  as  indicated  by  the  heavy  faced  type  on  Table  No.  3,  you  will 
find  the  percentage  of  overweight  or  underweight  nearest  his  actual  weight. 

FOR  MEN 

Table  No.   1 

STANDARD  WEIGHT  COLUMNS 

TABLE  OF  HEIGHT  AND  WEIGHT  AT  DIFFERENT  AGES 


Ages 

15-19 

20-24 

25-29 

30-34 

35-39 

40-44 

45-49 

50-54 

55-59 

60-64 

65-69 

5  ft. 

0 

in 

115 

120 

125 

128 

131 

133 

134 

134 

134 

131 

5  ft. 

1 

in 

118 

122 

126 

129 

131 

134 

136 

136 

136 

134 

5  ft. 

2 

in 

120 

124 

128 

131 

133 

136 

138 

138 

138 

137 

5  ft. 

3 

in 

123 

127 

131 

134 

136 

139 

141 

141 

141 

140 

140 

5  ft. 

4 

in 

127 

131 

135 

138 

140 

143 

144 

145 

145 

144 

143 

5  ft. 

5 

in 

130 

134 

138 

141 

143 

146 

147 

149 

149 

148 

147 

5  ft. 

() 

in 

134 

138 

142 

145 

147 

150 

151 

153 

153 

153 

151 

5  ft. 

7 

in 

137 

142 

147 

150 

152 

155 

156 

158 

158 

158 

156 

5  ft. 

8 

in 

141 

146 

151 

154 

15V 

160 

161 

163 

163 

163 

162 

5  ft. 

f) 

in 

145 

150 

155 

159 

162 

165 

166 

167 

168 

168 

168 

5  ft. 

10 

in 

149 

154 

159 

164 

167 

170 

171 

172 

173 

174 

174 

5  ft. 

11 

in 

154 

159 

164 

169 

173 

175 

177 

177 

178 

180 

180 

fi  ft. 

0 

in 

160 

165 

170 

175 

179 

180 

183 

182 

183 

185 

185 

fi  ft. 

1 

in 

163 

170 

177 

181 

185 

186 

189 

188 

189 

189 

189 

6  ft. 

1 

in 

168 

176 

184 

188 

192 

194 

196 

194 

194 

192 

192 

6  ft. 

3 

in 

172 

181 

190 

195 

200 

203 

204 

201 

198 

FOR  WOMEN 

Table  No.  2 

STANDARD  WEIGHT  COLUMNS 

TABLE  OF  HEIGHT  AND  WEIGHT  AT  DIFFERENT  AGES 


Ages 

15-19 

20-24 

25-29 

30-34 

35-39 

40-44 

45-49 

50  and 
over 

4  ft. 

5  ft. 
5  ft. 
5  ft. 
5  ft. 

11  in 

0  in 

1  in 

2  in 

3  in 

111 
113 
115 
117 
120 
123 
125 
128 
132 
136 
140 
144 

113 
114 
116 
118 
122 
125 
128 
132 
135 
140 
144 
147 

115 
117 
118 
120 
124 
127 
131 
135 
139 
143 
147 
151 

117 
119 
121 
123 
127 
130 
135 
139 
143 
147 
151 
155 

119 
122 
124 
127 
131 
134 
139 
143 
147 
151 
155 
159 

122 
125 
128 
132 
135 
138 
143 
146 
150 
155 
159 
103 

125 
128 
131 
134 
138 
142 
147 
151 
154 
158 
163 
107 

128 
130 
133 
137 
141 

5  ft. 
5  ft. 
5  ft. 

4  in 

5  in 

6  in 

145 
149 
153 

5  ft. 
5  ft. 

7  in 

8  in 

157 
161 

5  ft. 

9  in 

166 

5  ft. 

10  in 

170 

Table  No.  3 


Underweight 

Standard 

Overweight 

25% 

20%, 

15%, 

20% 

30% 

40% 

45% 

S3 

89 

94 

111 

133 

144 

155 

161 

84 

90 

95 

112 

134 

146 

157 

162 

85 

90 

96 

113 

136 

147 

158 

164 

86 

91 

97 

114 

137 

148 

160 

165 

S6 

92 

98 

115 

138 

150 

161 

167 

S7 

93 

99 

116 

139 

151 

162 

168 

88 

■   94 

99 

117 

140 

152 

164 

170 

89 

94 

100 

lis 

142 

153 

165 

171 

89 

95 

101 

119 

143 

155 

107 

173 

90 

96 

102 

120 

144 

156 

108 

174 

650 


DIET  IN  DISEASE 


Table  No.  3 — Continued 


Underweight 

Standard 

Overweight 

257c, 

207o 

15% 

20% 

30% 

40% 

45% 

91 

97 

103 

121 

145 

157 

169 

175 

92 

98 

104 

122 

146 

159 

171 

177 

92 

.98 

105 

123 

148 

160 

172 

178 

93 

99 

105 

124 

149 

161 

174 

180 

94 

100 

106 

125 

150 

163 

175 

181 

95 

101 

107 

126 

151 

164 

176 

183 

95 

102 

108 

127 

152 

165 

178 

184 

96 

102 

109 

128 

154 

166 

179 

186 

97 

103 

110 

129 

155 

168 

181 

187 

98 

104 

111 

130 

156 

169 

182 

189 

98 

105 

111 

131 

157 

170 

183 

190 

99 

106 

112 

132 

158 

172 

185 

191 

100 

106 

113 

133 

160 

174 

186 

193 

101 

107 

114 

134 

161 

174 

188 

194 

101 

108 

115 

135 

162 

176 

189 

196 

102 

109 

116 

136 

163 

177 

190 

197 

103 

110 

116 

137 

164 

178 

192 

199 

104 

110 

117 

138 

166 

179 

193 

200 

104 

111 

118 

139 

167 

181 

195 

202 

105 

112 

119 

140 

168 

182 

196 

203 

106 

113 

120 

141 

169 

183 

197 

204 

107 

114 

121 

142 

170 

185 

199 

206 

107 

114 

122 

143 

172 

186 

200 

207 

108 

115 

122 

144 

173 

187 

202 

209 

109 

116 

123 

145 

174 

189 

203 

210 

110 

117 

124 

146 

175 

190 

204 

212 

110 

118 

125 

147 

176 

191 

206 

213 

111 

118 

126 

148 

178 

192 

207 

215 

112 

119 

127 

149 

179 

194 

209 

216 

113 

120 

128 

150 

180 

195 

210 

218 

113 

121 

128 

151 

181 

196 

211 

219 

114 

122 

129 

152 

182 

198 

213 

220 

115 

122 

130 

153 

184 

199 

214 

222 

116 

123 

131 

154 

185 

200 

216 

223 

116 

124 

132 

155 

186 

202 

217 

225 

117 

125 

133 

156 

187 

203 

218 

226 

118 

126 

133 

157 

188 

204 

220 

228 

119 

126 

134 

158 

190 

205 

221 

229 

119 

127 

135 

159 

191 

207 

223 

231 

120 

128 

136 

160 

192 

208 

224 

232 

121 

129 

137 

161 

193 

209 

225 

233 

122 

130 

138 

162 

194 

211 

227 

235 

122 

130 

139 

163 

196 

212 

229 

236 

123 

131 

139 

164 

197 

213 

230 

238 

124 

132 

140 

165 

198 

215 

231 

239 

125 

133 

141 

166 

199 

216 

232 

241 

125 

134 

142 

167 

200 

217 

234 

242 

126 

134 

143 

168 

202 

218 

235 

244 

127 

135 

144 

169 

203 

220 

237 

245 

128 

136 

145 

170 

204 

221 

238 

247 

128 

137 

145 

171 

205 

222 

239 

248 

129 

138 

146 

172 

206 

224 

241 

249 

130 

138 

147 

173 

208 

225 

242 

251 

131 

139 

148 

174 

209 

226 

244 

252 

131 

140 

149 

175 

210 

228 

245 

254 

132 

141 

150 

176 

211 

229 

246 

255 

133 

142 

150 

177 

212 

230 

248 

257 

134 

142 

151 

178 

214 

231 

249 

258 

134 

143 

152 

179 

215 

233 

251 

260 

DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 


651 


Table  No.  3 — Continued 


Underweight 

Standard 

Overweight 

25% 

20% 

1   15% 

20% 

30% 

40% 

45% 

135 

144 

153 

180 

210 

234 

252 

261 

136 

145 

154 

181 

217 

235 

253 

262 

137 

14G 

155 

182 

218 

237 

255 

264 

137 

14G 

156 

183 

220 

238 

256 

265 

138 

147 

156 

184 

221 

239 

258 

267 

139 

148 

157 

185 

222 

241 

259 

268 

140 

149 

158 

186 

223 

242 

260 

270 

140 

150 

159 

187 

224 

243 

262 

271 

141 

150 

160 

188 

226 

244 

263 

273 

142 

151 

161 

189 

227 

246 

265 

274 

143 

152 

162 

190 

228 

247 

266 

276 

143 

153 

162 

191 

229 

248 

267 

277 

The  present  day  conception  of  the  proper  way  to  manage  the  diet 
of  an  obese  person  is  to  determine  the  normal  weight  for  the  height 
and  age.  This  can  be  done  by  one  of  the  numerous  formulae  or  more 
conveniently  by  consulting  the  tables  such  as  are  used  by  the  life  in- 
surance companies.  The  preceding  table  shows  the  weights  for  males 
and  females.  The  female  weights  are  slightly  less  than  the  male. 
This  ideal  weight  if  in  kilograms  is  multiplied  by  35  or  if  in  pounds 
by  35  divided  by  2.2.  This  will  give  the  number  of  calories  required 
for  twenty-four  hours  by  a  patient  about,  but  not  at  hard  labor.  If 
the  individual  is  engaged  in  hard  labor  the  multiplying  number 
should  be  40  or  45,  according  to  the  amount  of  exertion  and  the 
length  of  time  it  is  engaged  in.  The  first  care  is  to  provide  for  suffi- 
cient protein,  which  is  necessary  to  the  maintenance  of  the  health 
and  strength  of  the  individual.  Ordinarily  this  may  be  placed  at 
about  100  grams  for  the  average  size  individual  and  increased  or 
decreased  according  to  their  size.  This  amount  of  protein  will  fur- 
nish 410  calories,  which  may  be  deducted  from  the  figures  as  deter- 
mined above.  The  remainder  may  be  made  up  by  properly  balanced 
ration  and  the  whole  diet  filled  out  by  the  use  of  bulky  foods  of  low 
caloric  value.  In  addition  to  the  diet  it  should  be  remembered  that 
the  exercise  of  the  individual  should  be  increased  and  if  necessary, 
in  chosen  cases  the  metabolism  increased  by  the  judicious  use  of 
thyroid  extract.     (See  Below.) 

The  easiest  way  to  apply  a  diet  for  obesity  is  to  use  the  suggestion 
of  Umber,  who  suggested  giving  the  so  called  skeleton  diet  and  then 
adding  to  this  accessory  articles,  each  portion  furnishing  100  calories, 
these  being  added  to  bring  up  the  diet  to  the  proper  number  of 
calories.     His  diet  as  given  by  Barker,  is  as  follows : 

The  following  "skeleton  diet"  amounts  to  about  880  calories,  con- 
taining 93.7  g.  protein;  this  may  be  supplemented,  according  to  the 
needs  of  the  particular  patient  by  an  "accessory-  diet,"  consisting  of 
given  portions  of  foods,  each  "accessory  portion"  corresponding  to 
a  food  value  of  100  calories. 


652  DIET  IN  DISEASE 

SKELETON  DIET  (=880  CALORIES) 

Morning: — 1  cup   (250  c.c. )   coffee  or  tea,  with  1  tablespoonful    (15  c.c.)    milk; 

1  small  slice  (50  g. )   brown  bread,  or  h  slice   (30  g.)   white  bread. 
Forenoon  : — 1  small  orange  or  1  small  apple,  or  similar  amount  of  other  fresh 

fruit. 
Noon: — 2  slices   (250  g. )  roast  meat;  2  portions   (200  g. )  green  vegetables  boiled 

in  salt  water:  a  little  fruit. 
Afternoon: — ^  cup   (125  c.c.)   coffee,  with  1  tablespoonful    (15  cc.)    milk. 
Evening: — One  slice  (100  g. )  meat,  or  a  little  chicken  or  ttsh  ;   1  portion   (100  g. ) 

green  vegetables:  i  slice  brown  bread    (25  g.)  ;   1  cup  tea:    (if  desired). 
At  bed  time: — a  little  raw  fruit. 

ACCESSORY  DIET   (EACH  PORTION  =  100  CALORIES) 

80  g.  roast  beef ;  200  g.  oysters :  40  g.  white  bread,  graham  bread  or  rye  bread ; 
20  g.  Zwieback,  12^  g.  butter;  20  g.  Swiss  cheese;  25  g.  sugar;  100  g.  pota- 
toes; 30  g.  rice,  peas,  beans,  or  buckwheat;  20  g.  flour;  200  g.  apples;  150  g. 
apple  sauce;  500  g.  cranberries;  150  g.  milk;  150  g.  wine;  30  g.  brandy  or 
whiskey. 

Accessory  Diet  of  Filling  Foods  of  Low  Caloric  Value 


100  g. 

cooked 

asparagus 

=  43  calories 

" 

green  beans 

=  20 

"   " 

" 

green  peas 

=  108 

i( 

tomatoes 

=  20 

"   " 

" 

spinach 

=  52 

"   " 

" 

turnips 

=  40 

In  the  front  part  of  this  volume  will  be  found  a  table  giving  the 
size  and  the  weight  of  the  various  foods  in  hundred  calories  por- 
tions. This  will  be  found  of  great  value  in  arranging  obesity  diets. 
The  patient  may  be  given  a  list  containing  the  proper  number  of 
calories  and  expressed  in  the  language  which  he  can  understand. 
There  will  also  be  found  another  table  showing  the  value  of  common 
foods  in  household  measures  and  one  giving  the  caloric  values  of 
the  common  foods  per  ounces  arranged  in  the  order  of  their  values. 
The  ones  at  the  beginning  of  the  list  may  be  used  rather  freely  up 
to  those  which  contain  20  calories  per  ounce,  which  are  forbidden  in 
most  instances  or  are  to  be  used  in  very  small  quantities,  and  inter- 
changed for  foods  of  smaller  values.  This  may  be  done  to  furnish  a 
variety  in  the  diet,  but  these  changes  should  be  carefully  considered 
in  order  to  avoid  giving  the  patient  more  than  he  should  have. 

The  protein  food  may  be  given  as  eggs  or  meat  and  the  remainder 
of  the  diet  of  filling  foods  of  low  caloric  value  are  added,  such  as 
vegetable  marrow,  spinach,  sea  kale,  onions,  turnips,  cabbage,  Savoy 
cabbage,  cauliflower,  parsnips,  beets,  carrots,  celery,  cucumbers, 
radishes,  asparagus,  artichokes,  green  peas,  Brussels  sprouts,  leeks, 
egg  plant,  squash,  salsify,  strawberries,  pineapple,  oranges,  lemons, 
cranberries,  raspberries,  blackberries,  apricots,  apples  and  pears. 

The  patient  should  be  instructed  that  there  are  certain  foods  that 
are  strictly  forbidden.  In  the  first  place  the  fatty  foods  should  be 
cut  out  of  the  diet.  These  include  bacon  and  fat  of  any  meat,  pork, 
on  account  of  its  containing  so  much  fat,  olive  oil,  butter  and  cream. 
Secondly,  the  foods  rich  in  carbohydrates.  These  include  sugar, 
bread,   biscuit,   crackers,   all   sorts   of   breadstuffs,   and   all   sorts   of 


DISEASES  I\   WHICH  DIET  IS  A   rRIMARY  FACTOR  653 

cereals  and  breakfast  foods  and  all  sorts  of  candies,  sweets,  ice  cream, 
cakes  and  sweet  desserts  as  well  as  rice  and  macaroni  and  corn  and 
dried  beans  and  lentils  and  potatoes.  Milk  and  cheese  are  generally 
forbidden,  but  skim  milk  or  whey  or  buttermilk  may  be  allowed. 
Wines  and  malt  liquors  and  spirits  of  all  kinds  are  strictly  forbidden. 

Starvation  Diet. — Folin  and  Denis  have  studied  some  cases  of 
unusually  fat  patients  and  suggest  that  an  effective,  and,  at  the  same 
time,  rapid  and  safe  method  of  reducing  the  weight  under  these 
conditions  is  by  a  series  of  repeated  fasts.  They  found  that  after 
about  four  days  acetone  bodies  began  to  be  greatly  increased  in  the 
urine  and  the  acidosis  was  relieved  by  interrupting  the  fasting  and 
placing  the  patient  on  a  diet  just  sufficient  to  cause  the  disappearance 
of  the  acetone  bodies  from  the  urine.  The  fasting  was  then  started 
again  and  interrupted  when  the  acidosis  began  to  make  itself  mani- 
fest. With  each  successive  period  of  starvation  the  onset  of  the 
acidosis  was  more  and  more  delayed.  By  checking  up  the  condition 
of  the  patient  by  studying  the  acetone  bodies  and  the  ammonium 
nitrogen  in  the  urine  they  believe  that  this  method  of  reduction  will 
be  found  very  valuable. 

Oertel's  Method. — Oertel  makes  the  following  suggestions  as  to  the 
treatment  of  the  various  classes  of  obesity,  always  considering  whether 
the  patient  is  plethoric  or  anemic: 

"(a)  Where  there  is  an  abnormally  increased  amount  of  fat  in 
plethoric  patients  with  unimpaired  or  only  beginning  changes  in  the 
heart  action  the  diet  should  aim  at — 

"  (1)  An  increased  supply  of  protein. 

"  (2)   A  decrease  in  the  fat-producing  substances. 

"(3)  Little  or  no  diminution  in  the  supply  of  liquids  below  the 
physiologic  amount  (1500  c.c. — 3  pints). 

"(6)  Where  there  is  obesity  in  anemic  patients,  viz.,  serous 
plethora,  the  diet  should  aim  at — 

"■  (1)   An  increase  in  the  quantity  of  proteins. 

"(2)  A  diminution  in  the  amount  of  fat-forming  substances,  and 
eventually- — 

''  (3)   A  decrease  in  the  amount  of  fluid. 

"(c)  Where  there  is  obesity  in  adults  with  hydremic  symptoms, 
in  whom  not  only  the  amount  of  protein,  but  also  the  abnormally 
increased  amount  of  fat  is  slowly  wasting  away,  they  require — 

"  (1)   An  increase  in  the  amount  of  protein  taken. 

"(2)  A  sufficient  amount  of  fat  and  carbohydrates  or  even  an 
increase  of  same  to  prevent  the  falling  off  of  fat. 

"(3)   A  diminution  in  the  amount  of  fluid  taken." 

Oertel  lays  particular  stress  on  the  fact  that  dietetic  rules  should 
be  based  upon  changes  in  the  heart,  and  consequently  of  the  circula- 
tion. Both  the  quality  and  the  quantity  of  food  and  drink  should  be 
considered.     If  the  circulation  is  disturbed,  small  excesses,  either  in 


654  DIET  ly  DISEASE 

food  or  in  drink,  will  give  rise  to  distress.  The  most  noticeable 
symptoms  are  a  feeling  of  oppression,  palpitation  of  the  heart,  and 
difficulty  in  breathing.  In  pronounced  cases  of  disturbances  of  the 
circulation,  if  too  hearty  a  meal  has  been  indulged  in,  death  may 
follow  slight  exertion.  In  these  cases  death  is  due  to  paralysis  of 
the  heart.  The  effect  of  the  meals  on  the  circulation  must  be  ob- 
served carefully,  the  amount  of  disturbance  following  a  meal  will 
determine  the  size  and  the  number  of  meals  that  must  be  taken. 

The  aim  of  the  treatment  is  to  furnish  food  and  exercise  in  such 
amounts  that  the  body  fat  may  be  burnt  up  and  thus  the  needed 
reduction  of  weight  take  place,  while  at  the  same  time  the  body  and 
heart  are  strengthened.  This  can  be  done  only  by  a  careful  study 
of  each  case.  In  a  word,  the  physician  must  discriminate  between 
those  cases  in  which  the  respiratory  and  circulatory  apparatus  have 
not  been  disturbed,  and  where  the  muscular  apparatus  is  in  such 
condition  that  a  considerable  amount  of  bodily  exercise  may  still  be 
taken,  and  those  cases  in  which  the  blood  is  poor,  where  advanced 
venous  stasis  reduces  the  absorption  of  oxygen  in  the  lungs  to  a 
minimum,  and  where  slight  muscular  exertion  exhausts  the  oxygen, 
interferes  with  respiration,  and  gives  rise  to  dyspneic  symptoms.  In 
the  first  class  a  liberal  amount  of  fat  and  carbohj'drates  may  be 
allowed — that  is,  as  large  a  quantity  as  the  patient  can  dispose  of 
in  his  body  by  exercise  without  defeating  the  objects  of  the  treat- 
ment. In  the  second  class  the  fats  and  carbohydrates  and  the  quan- 
tity of  fluid  taken  must  be  reduced  to  a  minimum. 

The  foods  given  must  be  such  as  will  supply  the  proper  amount 
of  nourishment  without  forming  fat.  The  following  are  equivalent 
in  heat  and  force  production,  or,  in  other  words,  they  are  said  to 
have  the  same  caloric  value:  100  grams  of  fat,  211  grams  of  protein, 
232  grams  of  starch,  234  grams  of  cane-sugar,  256  grams  of  grape- 
sugar  (240  grams  as  a  sugar  average).  To  make  this  more  clear  it 
must  be  remembered  that  a  body  stores  up  fat  if  more  than  118  grams 
of  protein  and  259  grams  of  fat,  with  a  caloric  value  of  2894,  are 
taken ;  but  110  grams  of  protein  and  600  grams  of  starch,  with  a 
caloric  value  of  2944,  may  be  given  without  producing  fat.  With  a 
mixed  diet  the  limit  lies  near  118  grams  of  protein,  100  grams  of  fat, 
and  368  grams  of  starch,  a  total  of  586  grams,  or  of  2923  calories. 
The  simplest  way  to  reduce  the  fat-forming  elements  is  to  diminish 
the  fat  and  allow  a  certain  amount  of  carbohydrates.  The  diet  must 
be  regulated  according  to  the  individual  case — this  is  a  point  that  can 
not  be  too  strongly  insisted  upon.  Oertel  gives  the  following  figures, 
based  on  numerous  calculations : 

17:Z.       gSL.       ^S.^        calories. 

Minimum     156  25  75  1180 

Maximum    170  45  120  1608 


DISEASES  I^'  ^^HICE  DIET  IS  A  PRIMARY  FACTOR  655 

The  amount  of  material  burnt  in  the  body  may  reach  from  2500 
to  3500  calories,  and  the  ditit'erence  between  that  supplied  by  the  food 
and  the  total  amount  used  is  taken  from  the  fat  stored  up  in  the 
body,  and  the  patient  loses  weight  accordingly. 

Oertel  lays  particular  stress  on  limiting  the  amount  of  fluid  taken. 
He  regards  1500  c.c.  as  the  physiologic  limit,  and  allows  more  than 
this — from  1800  to  2000  c.c. — only  in  very  tall  patients  or  when 
there  is  fever.  In  still  other  cases  he  reduces  the  amount  to  from 
750  to  1200  c.c. 

The  solid  food  is  to  be  taken  in  several  small  meals,  and  the  liquids 
are  to  be  taken  only  in  the  intervals  between  meals.  Soups  are  not 
permitted.  Five  or  six  meals  are  given  a  day,  their  frequency  obviat- 
ing the  necessity  for  eating  very  large  meals. 

If  the  patient  is  anemic,  the  breakfast  should  be  of  sufficient  size, 
but  should  not  include  either  tea  or  coffee. 

Oertel  regards  exercise  as  of  as  much  importance  as  diet.  In  the 
average  case  he  advises  from  four  to  five  hours'  outdoor  exercise 
dail,y,  taken  in  the  morning  and  afternoon.  If  the  patient  can  not 
take  that  much — and  he  rarely  can  at  first — he  is  given  exercises  of 
increasing  length  and  severity  until  the  required  amount  is  reached. 
The  increase  should  be  made  gradually,  and  should  depend  entirely 
on  the  patient's  condition.  He  should  be  told  the  distance  he  is  to 
walk,  and  not  the  time  in  which  he  is  to  do  it,  for  if  the  latter  is 
done,  a  lazj^  patient  may  do  much  less  than  is  necessary,  whereas  the 
energetic  or  ambitious  patient  may  overexert  himself. 

Oertel  insists  on  the  exercise  being  taken  in  the  open  air  and  on 
the  careful  regulation  of  the  amount  by  the  physician.  Where  it  is 
possible,  as  it  is  at  some  of  the  Continental  resorts,  the  paths  should 
be  of  four  difi^erent  grades.     These  are  as  follows: 

First     the  incline  from    0  to    5  degrees 

Second     ' the  incline  from    5  to  10  degrees 

Third     the  incline  from  10  to  15  degrees 

Fourth     the  incline  from  15  to  20  degrees 

A  pedometer  may  be  used  to  measure  the  amount  of  walking  done^ 
and  furnishes  a  convenient  means  of  prescribing  walking  exercises. 
Care  should  be  taken  to  use  only  a  reliable  instrument,  for  some  are 
very  inaccurate.  The  amount  of  exercise  is  regulated  according  to 
the  state  of  the  patient's  heart,  his  general  strength  and  condition, 
and  also  as  to  whether  he  is  plethoric  or  anemic.  Any  complications 
that  exist  must  also  be  taken  into  account. 

If  the  patient  is  plethoric  and  the  heart  is  in  good  condition,  he 
may  be  ordered  to  take  walks  of  the  first  and  second  grades  at  the 
outset,  the  distance  prescribed  being  about  that  which  an  ordinary 
individual  would  walk  in  from  one  and  one-half  to  two  hours.  This 
amount  should  be  divided  up  between  the  morning  and  afternoon,  as 
circumstances  may  warrant.     The  return  course  is  not   taken  into 


656  DIET  ly  DISEASE 

account.  The  patient  should  be  allowed  to  consume  as  much  time 
as  he  requires  in  walking  this  distance.  Care  should  be  taken  to 
avoid  overexertion.  Days  of  rest  may  be  interspersed  as  the  need  for 
them  arises.  The  distance  may  be  lessened  or  increased,  according 
to  the  case.  The  patient  should  use  the  paths  of  the  fourth  grade 
only  when  the  heart  has  become  strong  and  when  he  is  in  good  condi- 
tion, and  then  only  occasionally. 

The  patient  should  be  taught  to  breathe  deeply  and  regularly. 
Ordinarily,  if  he  gets  out  of  breath  easily,  he  may  be  allowed  an 
inspiration  and  an  expiration  for  each  step.  When  using  the  paths  of 
the  second  and  third  grades,  the  patient  may  from  time  to  time, 
for  short  intervals,  breathe  in  an  interrupted  (staccato)  manner, 
taking  one  inspiration  for  two  steps  and  then  two  expirations  within 
the  next  two  steps.  This  method  is  often  of  great  value  in  securing 
perfect  inspiration  and  expiration. 

If  the  patient  is  anemic  or  hydremic,  or  if  the  heart  action  is  im- 
paired, the  exercises  should  be  begun  on  level  ground  and  gradually 
increased  in  severity.  Several  weeks  or  more,  according  to  the  case, 
should  be  allowed  to  elapse  before  the  patient  is  permitted  to  try  the 
third  grade  paths. 

In  patients  with  sclerosis  and  atheroma  exercises  must  be  pre- 
scribed with  extreme  caution.  If  the  sclerosis  is  not  marked,  the  pa- 
tient may  derive  the  greatest  benefit  from  the  exercises,  but  the 
amount  and  the  variety  should  be  cautiously  prescribed  and  their 
effect  watched.  If  atheroma  is  present,  the  greatest  care  should  be 
taken  to  guard  against  overexertion.  In  all  these  cases,  however, 
exercises  should  not  be  entirely  dispensed  with,  although  the  amount 
may  be  limited  to  the  minimum. 

If  there  is  involvement  of  the  coronary  arteries,  whether  or  not 
stenocardic  attacks  have  taken  place,  only  the  smallest  amounts  of 
exercise  should  be  allowed,  and  these  should  be  on  level  ground.  It 
is  only  in  rare  cases  that  this  amount  should  be  dispensed  with,  for 
if  the  patient  remains  at  rest  and  the  fatty  condition  be  allowed  to 
progress,  the  patient  must  inevitably  become  very  weak. 

Exercise  is  contraindicated  in  myocarditis,  pronounced  albumin- 
uria, and  general  edema.  When  any  of  these  are  present,  rest  and 
proper  medication  are  to  be  advised. 

Diet  After  the  Treatment. — The  following  is  Oertel's  general  diet, 
which  is  to  be  modified  to  suit  the  individual  case. 

'^ Morning:  A  cup  of  coffee  or  tea  with  milk  (150  to  200  c.c. — 
5  to  6  ounces)  and  bread,  75  grams  (2i/2  ounces). 

'^ Forenoon:  In  cases  preceding  anemia  and  hydremia,  one  or  two 
soft-boiled  eggs  or  30  to  40  grams  (one  to  one  and  one-half  ounces) 
of  meat,  cold  or  freshly  broiled,  100  c.c.  (3  ounces)  of  wine,  or  in 
conditions  of  weakness  50  c.c.  (li/o  ounces)  port,  and  a  small  quantity 
of  bread. 


DISEASES  IN  WHICH  DIET  IS  A  PRIMARY  FACTOR 


657 


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salad  or  easily  digested  vegetables  at  discretion ;  likewise  fish  cooked 
42 


658 


DIET  IN  DISEASE 


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without  much  grease;  25  grams  (about  1  ounce)  bread  or  some 
farinaceous  food— at  most,  100  grams  (3  ounces)  ;  for  dessert,  fruit, 
100  to  200  grams  (3  to  6  ounces),  best  fresh  or  preserved  (especially 


THE  DEFICIENCY  DISEASES— VITAMINU  659 

after  Nageli's  method).  For  drink,  one-sixth  to  one-fourth  of  a 
liter  (6  to  8  ounces)  of  light  wine  or  beer;  water. 

"Afternoon:  Again,  150  to  200  c.c.  (5  to  6  ounces)  of  coffee  or 
tea,  with  about  one-fourth  of  a  liter  of  water  (one-half  pint)  and 
25  to  50  grams  (1  to  2  ounces)  of  bread  if  there  is  any  desire  for  it. 

"Evening:  Meat  as  at  noon,  or  eggs,  25  grams  (about  1  ounce) 
of  bread,  and  possibly  a  small  amount  of  cheese,  salad,  or  fruit. 
Beverage,  wine,  with  or  without  water,  or  beer,  best  taken  some  time 
after  the  meal — up  to  300  to  500  c.c.  (I/12  to  1  pint).  Delicacies, 
oysters,  caviare,  etc.,  by  reason  of  their  nourishing  qualities,  may 
be  eaten  between  or  before  meals,  but  so  that  they  do  not  too  much 
augment  the  total  quantity  of  food."  (See  Tables  I.  and  II.,  pages 
657  and  658. 

DIET  FOR  LEANNESS 

It  is  much  easier  to  reduce  a  patient  who  is  obese  than  to  fatten 
one  who  is  thin.  The  measure  of  success  is  largely  dependent  on  the 
cause  of  the  leanness.  About  one-half  of  all  thin  persons  are  so  from 
hereditary  causes,  and  time  and  energy  are  almost  wasted  in  an 
attempt  to  fatten  these.  When  there  is  a  definite  cause  for  the 
emaciation  and  this  can  be  discovered  and  removed,  much  can  be 
accomplished.  In  these  cases  relief  from  worry,  bustle,  and  excite- 
ment may  be  all  that  is  necessary.  ]\Iore  often  there  is  starch  dys- 
pepsia, or  the  patient  may  be  unable  to  take  sugar  without  inducing 
fermentation  and  flatulence. 

In  a  general  way,  the  following  suggestions  for  the  relief  of  lean- 
ness may  be  made:  The  patient  should  lead  a  quiet,  out-of-door  life, 
free  from  care  and  excitement,  and  should  get  sufficient  sleep.  The 
meals  should  be  ample,  and  as  much  carbohydrate  and  fatty  food 
should  be  taken  as  is  possible.  Cream,  milk  and  cream,  butter,  cocoa, 
and  chocolate,  bread,  cereals  (well  cooked),  farinaceous  puddings, 
potatoes,  legumes,  and  sweet  fruits  should  all  be  partaken  of  in 
abundance.  All  sweets — honey,  syrups,  cakes,  and  the  like — may 
be  taken  if  they  agree  with  the  digestion.  Beer,  especially  of  the 
darker  varieties,  brown  stout,  porter,  and  ale  are  useful.  If  wine  is 
preferred,  sweet  wines  or  port  should  be  chosen.  If  alcohol  is  con- 
traindicated,  malt  extracts  may  be  given. 

The  patient  should  avoid  strong  alcoholic  liquors,  acids,  spices, 
and  the  like,  as  well  as  many  green  vegetables.  In  a  word,  the  diet 
should  be  the  reverse  of  that  recommended  for  obesitv.  (See  Rest 
Cure.) 

THE  DEFICIENCY  DISEASES.— VITAMINS 

The  Vitamins. — Hoist  states  that  Cartier,  in  1535,  on  his  second 
voyage  to  New  Foundland,  cured  scurvy  by  giving  a  fresh  decoction 
of  pine  needles.  The  use  of  fresh  fruit  or  \egetables  as  a  cure  or 
preventative  of  scurvy  was  e?rly  recognized  and  the  action  of  the 


660  DIET  IN  DISEASE 

boards  or  traae  requiring  the  use  of  lime  juice  as  part  of  the  diet 
on  board  ship  did  much  to  prevent  it,  and  in  the  British  Navy  lime 
juice  was  used  from  1795  which  practically  did  away  with  the  disease 
in  the  navy,  although  it  still  continued  as  a  scourge  of  prisons  and 
of  armies.  Rickets,  it  was  found,  could  be  cured  or  prevented  by 
proper  diet  and  cod  liver  oil  was  found  to  have  an  especial  value  in 
connection  with  it.  In  1897,  Eijkman  produced  a  polyneuritis  in 
pigeons  fed  with  polished  rice  and  also  noted  that  beriberi  was  pro- 
duced by  a  diet  of  polished  rice  and  that  it  could  be  prevented  or 
cured  by  using  the  unpolished  rice.  Rohman,  in  1902,  found  that 
mice  fed  on  purified  food  materials  were  difficult  to  raise  and  could 
not  bring  forth  living  young.  In  1906,  Hopkins  called  attention  to 
the  fact  that  there  were  "accessory  factors"  in  the  diet  in  addition 
to  the  protein,  fat,  carbohydrate  and  salts  that  played  an  important 
part  in  the  nutrition  and  an  absence  or  deficiency  produced  diseased 
conditions.  Funk,  in  1912,  suggested  the  term  vitamins  and  it  has 
been  generally  adopted  on  account  of  its  simplicity,  although  there 
is  no  evidence  to  show  that  the  substances  are  amins,  and  McCullom 
has  suggested  that  the  substances  necessary  for  growth  are  either  « 
soluble  in  fat  or  water,  and  he  suggests  the  terms  fat  soluble  A  and 
water  soluble  B.  Funk  showed,  in  1911,  that  a  substance  could  be 
extracted  from  yeast  by  means  of  alcohol  that  would  cure  the  polvTieu- 
ritis  of  fowls  and  it  has  since  been  demonstrated  that  active  extracts 
from  rice  bran  will  cure  beriberi  and  extracts  from  the  germ  of  corn 
will  do  the  same  in  pellagra.  This  whole  subject  is  very  intimately 
associated  with  the  vital  substances  necessary  for  growth  considered 
elsewhere,  but  we  must  mention  in  this  connection  that  if  animals  are 
fed  on  purified  food  stuft's  it  is  necessary  to  add  vitamins  such  as 
cure  beriberi  for  example,  and  also  those  soluble  in  fat  as  found  in 
butter.  The  fat  soluble  B  is  found  in  animal  fats,  but  apparently 
not  in  vegetable  oils.  For  further  details  and  concerning  what  is 
known  as  to  the  chemical  composition,  the  reader  is  referred  to  such 
compilations  as  Lusk's  (The  Science  of  Nutrition),  or  to  the 
abundant  special  articles  which  are  too  numerous  to  mention  here. 
These  all  important  substances  are  to  be  found  in  the  ordinary 
fresh  untreated  foods  and  they  are  for  the  most  part  inactivated  by 
heat  and  their  action  lessened  or  abolished  by  age.  This  means  that 
fresh,  unheated  foods  must  be  used  in  connection  with  the  preven- 
tion or  cure  of  the  deficiency  diseases.  Antiscorbutics  are  abundant 
in  fresh  orange  juice  and  a  sufficiency  in  bottled  lime  juice.  The 
antirachitic  substances  seem  to  be  in  the  animal  fats  and  also  in 
fresh  animal  proteins.  The  vitamins  essential  for  the  cure  of  beri- 
beri and  pellagra  are  found  in  the  pericarp  of  rice  (beriberi)  or  of 
corn  (pellagra),  in  the  germ  of  corn,  in  fact  in  the  outside  covering 
of  most  or  all  grains,  in  the  legumes  as  peas  and  beans  and  in  fresh 
meat. 


THE  DEFICIENCY  PISEASES—VITAMiyS 


661 


There  is  some  question  whether  there  are  specific  vitamins  or  not, 
but  apart  from  those  soluble  in  fat  and  in  water  we  need  not  concern 
ourselves  over  this  point  at  this  time,  but  await  further  investigation ; 
it  would  seem,  however,  that  wdth  the  exception  just  stated  that  they 
are  interchangable,  although  doubtless  some  are  much  more  efficient 
than  others. 

There  is  no  method  at  present  to  determine  the  vitamin  content 
of  any  given  food  except  by  animal  observations  which  of  course  are 
not  practicable.  The  phosphorous  content  however  seems  to  parallel 
it  and  Fraser  and  Stanton  found  that  rice  containing  less  than  0.4 
per  cent,  of  phosphorous  pentoxid  is  deficient  in  vitamins  and  Myers 
and  Voegtlin  found  the  same  to  be  true  of  wheat  and  corn.  The  fol- 
lowing table  illustrates  this  point : 


Wheat  bread  made  from  highly  milled  flour 

Whole  wheat 

Corn  grits  ( highly  milled )    

C'orn  grits   (highly  milled)    

Corn  meal    (highly  milled)    

Corn  meal  ( old-fashioned  rock  ground )    .  .  . 

Corn  meal   ( rock  ground )    

Corn  germ    

Corn,  whole    


Per  cent,  of 
P2O5  in 
dry  food. 


0.114 

1.120 

0.169 

0.210 

0.30 

0.659 

0.772 

2.816 

0.760 


Number  of  days  required  for 
ai)i)earance  of  polyneuritis 
in  fowl  fed  exclusively  on 
this   food. 


20-32  days. 

No  symptoms  developed. 

23-50  days. 

30  days.  " 

35  days. 

Remained  well. 

Remained  well. 

Remained  well. 

Remained  well. 


A  general  antideficiency  diet,  either  for  prevention  or  cure  must 
contain  first,  fresh  food,  neither  too  old  nor  sterilized  by  heat;  sec- 
ondly, it  must  contain  foods  known  to  be  rich  in  vitamins ;  and  lastly, 
it  should  contain  fresh  animal  fats,  preferably  butter.  Such  a  diet 
would  include  fresh  fruit  and  fresh  vegetables ;  fresh  meats ;  and 
legumes  fresh  or  dried  (not  canned),  peas  and  beans  or  lentils; 
flours  made  by  under  milling  the  grains  or  whole  grain  flour. 

Diets  which  are  liable  to  produce  deficiency  diseases  are  those  com- 
posed of  preserved  foods,  such  as  salt  meats,  old  dried  vegetables  or 
legumes,  and  canned  foods;  those  which  are  one-sided  and  are  too 
largely  made  up  of  cereals  or  carbohydrates  and  particularly  so  when 
the  outer  part  of  the  grain  has  been  removed  b.y  milling.  Such  diets 
are  found  in  the  South  where  corn  meal  is  largely  used  with  the 
resulting  pellagra ;  in  the  tropics  where  polished  rice  is  the  staple  diet 
with  the  resulting  beriberi ;  in  some  institutions  or  on  vessels  where 
the  element  of  freshness  has  been  neglected  with  the  resulting  scurvy, 
and  so  on. 

Many  persons  are  compelled  to  live  on  deficiency  disease  producing 
diets  through  poverty  or  ignorance.  They  cannot  afiPord  meats  in 
any  quantity.  Such  people  should  be  in.structed  by  the  government 
authorities  as  to  the  diet  best  suited  for  their  needs  and  in  the  use  of 


662 


DIET  IN  DISEASE 


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THE  DEFICIENCY  DISEASES— VITAMIXS  663 

the  milled  grains  and  the  free  use  of  beans  and  peas,  fresh  or  dried 
(not  canned). 

There  are  differences  in  the  susceptibilities  of  various  persons  to 
the  lack  of  vitamins  and  apparently  some  fed  on  deiicient  diet  do 
not  develop  marked  diseased  conditions.  This  is  probably  due  to 
their  getting  vitamin  containing  foods  at  various  times  of  the  year 
and  so  escape,  but  if  carefully  examined  they  may  show  some  of  the 
symptoms  in  a  somewhat  undeveloped  or  fruste  form.  Attention  to 
this  in  the  future  will  probably  clear  up  many  obscure  disease  con- 
ditions. 

\ 

Bone  lesion  at  epiphyses  of  long  bones 

Bone  lesion  at  junction  of  rib  and  cartilage.  . 


Periosteal  hemorrhages    

Subcutaneous   muscular   subserous   and   joint 
hemorrhages    


Spongy  gums 

Nerve   degenerations     

Cardiac  liypertrophy  and  degeneration 


\ 

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Dropsy    

Palsy    

Chart  showing  affinities  of  the  food  deficiency  syndromes. 

The  deficiency  diseases  include  rickets ;  the  scurvies,  infant,  adult 
and  of  guinea  pigs  (experimental)  ;  tropical  and  ship  beriberi,  doubt- 
less degrees  of  the. same  disease  and  here  may  be  included  the  in- 
fantile beriberi  described  in  the  Philippines  as  ''Taon";  the  ex- 
perimental polyneuritis  of  fowls,  and  pellagra.  These  diseases  are 
apparently  all  due  to  a  food  deficiency  in  the  matter  of  vitamins  and 
they  are  all  susceptible  of  further  investigations  as  there  are  many 
points  that  need  clearing  up.  They  have  certain  symptoms  in  com- 
mon, but  they  do  not  all  have  the  same  grouping  of  the  symptoms. 
The  most  important  of  the  symptoms  are  paralysis;  dropsy;  cardiac 
sj'mptoms  including  dilatation  of  the  right  heart,  dyspnea,  cyanosis 
and  oliguria;  spongy  gums;  a  tendency  to  hemorrhage  skin-,  and 
bone  changes.  This  is  very  well  shown  in  the  figure  from  Darling 
(Journ.  Am.  Med.  Assn.,  Oct.  10,  1914). 

The  pellagra  syndrome  includes  stomatitis,  gastro-intestinal  symp- 
toms, erythema  and  multiple  nervous  lesions.  Darling  omitted  it 
from  the  table,  but  we  have  added  it  in  the  table  given  on  the  preced* 
ing  page. 


664  DIET  IN  DISEASE 

SCORBUTUS  OR  SCURVY 

It  is  a  curious  fact  that  as  scurvy  has  become  less  and  less  cammon 
in  adults,  it  has  become  more  and  more  prevalent  in  infants. 

Scurvy  in  adults  occurs  when  there  is  a  deficiency  of  fresh  food. 
If  fresh  fruits,  fresh  vegetables,  and  fresh  meats  are  omitted  from  the 
dietary  for  any  length  of  time,  scurvy  is  almost  certain  to  follow. 
It  is  the  scourge  of  armies  that  have  been  forced  away  from  their 
bases  of  supplies  in  an  unproductive  country,  where  the  commissary 
department  is  inadequate.  During  the  late  civil  war  15  per  cent, 
of  the  deaths  were  said  to  be  due  to  scurvy.  In  former  years,  when 
the  sailor  was  not  so  well  cared  for  as  he  is  at  present,  the  disease  was 
common  on  shipboard.  It  is  apt  to  occur  in  prisons  and  where  the 
hygienic  surroundings  are  faulty. 

It  is  unnecessary  to  discuss  here  the  many  theories  promulgated 
regarding  the  nature  of  the  disease.  Suffice  it  to  say  that  fresh  food 
contains  a  principle,  be  it  salts  or  some  unknown  substance,  without 
which  man  can  not  continue  in  health.  This  substance  does  not  occur 
alone  in  vegetables,  for  the  Eskimos,  who  eat  practically  no  vegetables 
or  cereals,  are  not  especially  affected  by  the  disease.  It  is  the  quality 
of  the  food  and  not  the  quantity  eaten  that  is  the  causative  factor. 

The  prophylactic  treatment  of  this  disease  is  important,  and  has 
been  recognized  for  many  years.  The  boards  of  trade  did  much  to 
prevent  the  disease  among  sailors  by  requiring  that  on  all  long 
voyages  where  fresh  food  could  not  be  carried  lime-juice  be  given  to 
the  men  in  sufficient  quantities.  With  the  introduction  of  better 
methods  of  preserving  food  the  tendency  to  scurvy  has  been  lessened^ 
although  canned  foods  do  not  form  an  ideal  preventive  against  scurvy. 
If  fresh  meats  and  vegetables  cannot  be  obtained,  canned  vegetables 
and  fruits,  as  well  as  vinegar,  lime-juice,  or  lemon-juice,  should  be 
supplied.     Onions  are  also  valuable. 

The  treatment  of  scurvy  is  very  simple  and  mainly  dietetic.  The 
patient  should  be  placed  upon  a  good  nutritious  diet  of  fresh  food. 
Lime-,  lemon-,  or  orange-juice  should  be  given  freely.  Potatoes, 
onions,  and  all  varieties  of  green  vegetables  should  be  used  plenti- 
fully, and  fresh  milk  should  be  given.  If  the  mouth  is  so  sore  as  to 
interfere  with  mastication,  soups  and  broths,  made  of  the  articles 
just  mentioned,  and  fresh  fruit-juices  should  be  given.  Wright  has 
expressed  the  opinion  that  the  neutral  citrates  and  tartrates  are 
better  than  the  fresh  fruit-juices,  since  the  latter,  he  believes,  are 
apt  to  prolong  the  oozing  of  blood  from  the  mouth.  Practically, 
however,  there  is  no  reason  why  the  fresh  fruit-juices  should  not  be 
given,  for  they  seem  to  act  admirably.  When  the  proper  dietetic 
means  are  not  at  hand  to  treat  the  case,  every  effort  should  be  made 
to  secure  some  form  of  green  vegetables  or  berries.  Acetic  acid  or 
the  chlorate  or  bitartrate  of  potash  may  also  be  prescribed. 


TEE  DEFICIENCY  DISEASES— VITAMINS  665 

Infantile  Scurvy  (Barlow's  Disease). — One  of  the  best  contribu- 
tions to  this  subject  is  the  American  Pediatric  Society's  Collective 
Investigation  of  Infantile  Scurvy,  1898.  In  this,  379  cases  were  re- 
ported. Age  is  a  marked  factor,  and  four-fifths  of  the  cases  were 
between  the  sixth  and  the  fifteenth  month,  and  one-half  between  the 
seventh  and  the  tenth  month.  The  feeding  prior  to  the  onset  of  the 
disease  was  as  follows : 

Breast   milk    in    12  cases ;  alone  in  10. 

Raw  cows'  milk    in      5       •'  "     "     4. 

Pasteurized   milk    in    20       "  "     "16. 

Condensed   milk    in    60       "  "     "32. 

Sterilized  milk    in  107       "  "     "68. 

Proprietary    foods    in  214       " 

From  the  foregoing  table  it  will  be  seen  that  the  proprietary  foods 
are  the  most  frequent  cause,  sterilized  milk  being  next  in  frequency. 
Condensed  milk,  likewise,  is  not  to  be  overlooked  as  a  cause.  One 
should  be  cautious  not  to  keep  a  child  on  sterilized  or  condensed 
milk  for  too  long  a  time,  and  this  should  be  explained  to  the  mother. 
If  circumstances  necessitate  the  use  of  any  of  these  foods,  a  tea- 
spoonful  of  fresh  orange-juice  or  a  portion  of  baked  apple  should  be 
given  every  day  or  every  few  days.  The  proprietary  foods  that  are 
to  be  mixed  with  water  alone  should  never  be  used  except  as  a  tem- 
porary expedient  in  illness. 

The  treatment  of  infantile  scurvy,  unless  complicated  by  other 
diseases  or  associated  with  marasmus,  is,  if  properly  conducted,  most 
satisfactory  and  simple.  It  is  purely  dietetic.  The  infant  should 
be  placed  on  a  suitable  mixture  of  pure  fresh  milk,  according  to  the 
rules  laid  down  for  the  feeding  of  infants.  Some  form  of  fresh  fruit- 
juice,  scraped  ripe  apple,  or  grapes  from  which  skins  and  seeds  have 
been  removed,  or  any  fresh  ripe  fruit,  may  be  used.  From  one-half 
to  three  or  four  ounces  may  be  given  daily.  Among  the  very  poor 
the  authors  have  used  lemon-juice  with  benefit.  Potatoes  have  been 
highly  recommended,  especially  for  older  infants.  A  well-baked, 
mealy  potato  is  beaten  up  with  a  small  quantity  of  milk  to  the  con- 
sistence of  thick  cream,  and  a  teaspoonful  or  two  of  this  is  added 
to  each  bottle. 

Hess  has  called  attention  to  what  he  calls  latent  scurvy  which 
develops  slowly  as  a  result  of  insufficient  vitamins.  The  diagnosis 
rests  largely  on  the  disappearance  of  the  symptoms — stationary 
weight,  pallor,  poor  appetite  etc. — following  the  administration  of  an 
antiscorbutic.  He  also  calls  attention  to  the  fact  that  in  some  cases 
all  antiscorbutics  do  not  act  equally  well,  potato  being  better  in  some 
cases  than  orange  juice  and  vice  versa.  Orange  peel  rubbed  up  in 
water  may  also  be  used  as  an  effective  antiscorbutic. 

The  symptoms  will  usually  become  less  marked  in  a  few  days,  and 
in  uncomplicated  cases  of  average  severity  complete  recovery  will 


666  DIET  IN  DISEASE 

follow  in  one  or  two  weeks.     When  there  is  anemia,  cod-liver  oil  and 
iron  are  of  service. 

BERIBERI  OR  XAKKE 

This  disease  is  seen  throughout  the  tropics  and  in  a  somewhat 
milder  form  on  board  ships  where  the  food  is  not  of  the  proper  quality. 
The  ship  beriberi  has  less  involvement  of  the  nerves  and  palsy  is 
rare.  It  has  been  reported  in  the  fishermen  of  Newfoundland  and 
elsewhere  too  often  to  need  comment.  A  full  account  will  be  found 
in  Vedder's  monograph,  published  in  1913. 

It  is  definitely  a  deficiency  disease  produced  generally  from  eating 
a  diet  composed  too  exclusively  of  polished  or  highly  milled  rice,  but 
it  may  be  produced  by  other  diets  deficient  in  vitamins.  For  example, 
"Walcott,  who  reported  the  disease  from  the  Amazon  Basin,  ascribed 
at  least  a  part  of  it  to  the  use  of  farina  de  agua,  a  flour  made  by 
the  prolonged  maceration  of  the  wild  or  poisonous  mandioca  (Mani- 
hot  utilissima),  which  is  extensively  used  by  the  Brazilian  laborers. 

That  the  disease  is  due  to  faulty  diet  is  abundantly  proved  by 
observations  on  animals,  by  producing  it  in  the  human  being  by 
feeding  experiments  as  has  been  done  by  Fraser  and  Stanton  (Studies 
from  the  Institute  for  Medical  Eesearch,  Federated  JNlalay  States, 
1909,  No.  10),  and  by  Strong  and  Crowell  (Philippine  Journal  of 
Science,  1912,  A^I,  271),  as  well  as  by  the  fact  that  it  has  been 
eradicated  from  many  institutions  and  groups  of  soldiers,  sailors  or 
laborers.  These  are  so  well  known  that  one  need  only  mention  the 
eradication  from  the  Japanese  army  and  navy,  from  the  Philippine 
scouts  (Chamberlain,  Journal  Am.  Med.  Assn.,  April  24,  1915,  1215), 
from  the  laborers  of  Java  and  in  Brazil.  Eijkman,  as  mentioned 
above,  produced  the  same  or  an  analogous  disease  in  fowls  and  also 
showed  that  rice  polishings  M'ould  cure  the  disease.  Fraser  and 
Stanton  then  demonstrated  that  the  active  substance  could  be  dis- 
solved out  of  rice  polishings  by  0.3  per  cent,  hydrochloric  acid  and 
that  it  was  soluble  in  alcohol.  Chamberlain  and  Yedder  found  that 
the  protective  substance  was  soluble  in  water,  but  not  in  ether  and 
that  it  was  dialysable.  They  also  showed  that  this  extract  would 
cure  the  disease  as  seen  in  infants  with  remarkable  rapidity.  Wil- 
liams (Vedder,  Journ.  Am.  Med.  Assn.,  Nov.  19,  1917,  1494),  has 
succeeded  in  preparing  a  substance  synthetically  that  is  capable  of 
curing  the  disease  as  it  occurs  in  fowls. 

Unpolished  or  slightly  polished  rice  has  been  found  to  contain  0.5 
to  9.75  of  phosphorous  pentoxid  and  as  a  means  of  prevention  the 
prohibition  of  rice  containing  less  than  0.4  per  cent,  has  been  sug- 
gested. Fifteen  grams  of  rice  polishing  mixed  with  milk  and  sugar 
given  twice  daily  is  used  as  an  effective  cure. 

The  disease  may  be  produced  not  only  by  a  diet  made  up  too 
largely  of  rice,  but  also  by  the  too  exclusive  use  of  other  highly 


THE  DEFICIENCY  DISEASES— VITAMINS  667 

milled  flours,  of  hominy,  tapioca,  sago,  and  in  fact  by  foods  rich  in 
carbohydrates  in  general.  Sterilized  foods,  such  as  canned  and  other 
heated  products  have  the  same  action.  Why  the  deficient  diet  should 
produce  scurvy  at  one  time,  beriberi  at  another  and  pellagra  at  an- 
other is  still  an  unanswered  question,  but  it  would  point  to  there 
being  specific  or  at  least  different  vitamins  differing  not  only  in  what 
changes  a  deficiency  produces  in  the  body,  but  also  in  their  rapidity 
of  action, 

Vedder  gives  the  following  simple  rules  for  the  prevention  of  the 
deficiency  diseases : 

1.  In  any  institution  where  bread  is  the  staple  article  of  diet,  it 
should  be  made  from  whole  wheat  flour. 

2.  AVhen  rice  is  used  in  any  quantity,  the  brown  under  milled,  or 
so  called  hygienic  rice,  should  be  furnished. 

3.  Beans,  peas  or  other  legumes,  known  to  prevent  beriberi,  should 
be  served  at  least  once  a  week.  Canned  beans  or  peas  should  not 
be  used, 

4.  Some  fresh  vegetable  or  fruit  should  be  issued  at  least  once  a 
week  and  preferably  at  least  twice  a  week. 

5.  Barley,  a  kno^vn  preventive  of  beriberi,  should  be  used  in  all 
soups. 

6.  If  cornmeal  is  the  staple  of  diet,  it  should  be  yellow  meal  or 
water-ground  meal,  that  is,  made  from  the  whole  grain. 

7.  White  potatoes  and  fresh  meat,  known  preventives  of  beriberi 
and  scurvy,  should  be  served  at  least  once  a  week,  and  preferably 
once  daily. 

8.  The  too  exclusive  use  of  canned  goods  must  be  carefully  avoided. 
Vedder  feels  sure  that  the  strict  application  of  these  rules  will 

eradicate  scurv^y  and  beriberi,  and  believes  that  they  would  be  equally 
efticacious  in  eradicating  pellagra  from  the  United  States. 

Walcott  states  that  since  1912  the  treatment  at  Candelaria  Hospital 
for  beriberi  has  been  changed  to  a  strict  dietary  condition  consist- 
ing of : 

1.  Soups  of  beans  and  peas,  fresh  vegetables,  fish  chowder  and 
eggs. 

2.  Meats:  all  varieties,  but  served  in  underdone  condition. 

3.  Eggs,  usually  six  daily. 

4.  Fresh  cows'  milk  several  times  daily. 

5.  Irish  potatoes,  beans  and  peas  and  other  fresh  vegetables. 

6.  Fresh  fruits. 

7.  Rice  bran  two  times  daily. 

8.  No  bread  allow^ed  as  there  is  no  whole  wheat  or  graham  or  rye 
bread  to  be  had  here  as  yet. 

Chamberlain  gives  the  following  dietary  used  by  the  Philippine 
scouts  and  which  have  been  found  to  be  efficient  in  preventing  the 
disease. 


668 


DIET  IX  DISEASE 


TABLE  FILIPINO  RATION,  ARMY  REGULATIONS  1913,  PARAGRAPH  1205, 
IN  FORCE  FROM  JUNE,   1911,  TILL  PRESENT  DATE  i 


Component  Articles. 
Beef,  fresh    

Flour     

Baking  powder,  when  in 
field  and  ovens  are  not 
available      

Rice,  unpolished    

Potatoes    

Coffee,  roasted  and 
ground     

Sugar     

Vinegar     

Salt    

Pepper,   black    


Juantities, 
Ounces. 


12 


0.32 
20 


1 
2 

0.08 
0.64 
0.02 


Substitutive 
Article.?. 


Bacon 

Canned  meat 

Fish,  canned 

Fish, fresh 

Hard  bread 

Soft  bread 


Onions 


Quantities, 
Ounces. 


12 
12 

8 


PELLAGRA      (Maidismus) 

The  first  description  of  pellagra  was  by  a  Spanish  physician, 
Casals,  in  1707.  He  noticed  the  presence  of  the  disease  in  the 
Asturias  and  ascribed  it  to  an  insufficient  diet.  In  1771,  Frapoli 
gave  it  the  name  pellagra,  a  word  meaning  rough  skin,  referring  to 
the  ver}'  evident  cutaneous  lesions,  in  addition  to  which  were  the 
deterioration  of  the  nervous  sj-stem  and  progressive  weakness.  In 
1810,  Mazari  thought  the  disease  was  due  to  spoilt  maize  and  two 
schools  arose,  zeists  claiming  maize  as  a  causative  factor,  and  an- 
tizeists,  who  believed  that  there  was  some  other  cause.  Among  the 
former  was  Lombroso,  and  among  the  latter  of  recent  years  is 
Sambon,  who  had  a  theory  that  the  disease  was  caused  by  an  in- 
fectious agent  transferred  by  gnats. 

There  seems  to  be  little  doubt  at  the  present  time,  owing  to  the 
numerous  investigations  that  have  been  undertaken,  that  the  disease 
is  intimately  connected  with  the  diet  and  is  probably  due  to  a  de- 
ficiency of  vitamins.  Some  have  held  that  the  disease  was  due  to 
the  anaphylactic  action  of  the  grain,  and  still  another  theory  is  that 
the  use  of  maize  as  a  food  introduces  a  substance  into  the  blood  which 
is  acted  on  by  sunlight,  the  exposed  portions  of  the  body  suffering 
more  than  those  that  are  covered.  This  is  the  so  called  photodynamic 
theory.  The  disease  is  five  times  more  common  in  women  who  re- 
main in  the  house  than  in  men. 

In  the  corn  the  vitamins  are  present  in  the  germ  and  this  is  at  the 
exposed  place  on  the  grain  and  is  apt  to  be  injured  or  undergo  changes 

1  "Scout  organizations  will  be  required  to  use  the  entire  allowance  of  the  meat 
component,  and  not  more  than  16  ounces  of  rice  per  day  to  be  used  for  each  ration. 
The  purchase  of  1.6  ounces  of  beans  per  ration  in  substitution  of  the  portion  of 
the  rice  ration  not  drawn  will  be  made,  and  use  of  as  large  an  extent  as  possible 
of  native  products,  such  as  camotes,  mongos  and  squash,  will  be  required." 


ler  cent. 

per  cent. 

per  cent. 

per  ceut. 

9.2 

1.9 

74.4 

1.0 

9.0 

7.0 

70.0 

9.0 

21.7 

29.6 

44.7 

12.2 

1.5 

85.0 

THE  DEFICIENCY  DISEASES— MrAMINS  669 

from  external  agencies  and  in  the  modern  milling  of  corn  what  is 
known  as  degermination  is  practiced,  which  removes  the  germ  which 
is  sold  under  the  name  of  corn  chops  as  a  cattle  food.  Sometimes  a 
granulated  cornmeal  is  made. 

Wood  has  studied  the  composition  of  corn  chops  and  cornmeal  with 
the  following  results: 

Protein,  Pat.  Carbohydrate,         Fiber, 

Meal     

Chops 

Germ   alone 

Endosperm      

He  also  analyzed  various  flours  with  reference  to  their  content  in 
phosphorous  pentoxid.     The  results  are  very  interesting. 

P2O5 

per  cent. 

Corn   chops    1.15 

Water  ground  meal   (North  Carolina)    0.78 

Whole  meal,  steam  milled    ( Virginia)    0.60 

Highly  milled  meal    ( Ohio )     0.29 

Steam-milled  meal    (Nort'.,  Carolina)     0.58 

Wheat  middlings   (offal  of  mill)    0.98 

Whole-wheat  flour    0  50 

Average  wheat  flour    (bought  in  Wilmington,  North  Carolina) 0.14 

There  are  numerous  references  of  the  disease  being  produced  in 
human  beings  by  feeding  flours  and  cereals.  Nightingale,  in  Rhodesia, 
noted  it  in  prisoners  and  efliected  an  immediate  cure  by  the  use  of 
whole  cornmeal.  Little  observed  polyneuritis,  similar  to  beriberi  or 
identical  with  it,  due  to  deticient  diets,  and  observations  have  also 
been  made  on  chickens  and  other  fowls  in  which  polyneuritis  may  be 
produced  by  feeding  them  on  foods  lacking  in  vitamins.  This  can 
be  cured  promptly  by  the  feeding  of  corn  chops  or  other  foods  rich 
in  vitamins.  Wood  suggests  the  use  of  corn  chops  fed  to  human  be- 
ings and  has  used  it  in  several  cases  with  striking  results.  It  keeps 
poorly,  however,  and  must  be  used  fresh  to  be  of  any  value.  A 
material  may  be  extracted  from  it,  but  only  by  the  use  of  enormous 
amounts  of  alcohol,  rendering  the  cost  much  too  great  for  ordinary 
use. 

Wood  has  called  attention  to  the  fact  that  the  disease  was  not 
present  in  the  south  prior  to  the  civil  war,  and  the  old  water  mills 
ground  a  coarse  whole  grain  flour,  and  he  has  not  been  able  to  find 
the  disease  in  the  remoter  districts,  where  the  modern  innovations 
have  not  reached.  Voegtlin,  Myers,  and  Sullivan  have  demonstrated 
that  the  vitamins  are  destroyed  by  the  use  of  soda  and  by  certain 
baking  powders  in  the  preparation  of  bread,  regardless  of  the  original 
quality  of  the  flour  or  meal.  They  also  showed  that  the  use  of  sour 
milk  in  connection  with  the  soda  would  prevent  this  destruction  and 
that  baking  powders  that  contain  enough  tartaric  acid  to  neutralize 


670  DIET  IN  DISEASE 

the  sodium  carbonate  after  the  production  of  the  carbon  dioxid  woul(J 

not  destroy  the  vitamins.  \ 

Lombroso  said  that  it  is  impossible  to  cure  the  disease,  because  he 
might  as  well  advise  his  patients  to  be  rich  as  to  eat  a  diet  which 
they  could  not  afford,  and  if  a  patient  were  rich  he  would  have  the 
proper  food  and  so  not  have  the  disease. 

The  prevention  means  a  better  diet,  one  richer  in  proteins.  Studies 
made  on  the  pellagrins  show  that  they  are  on  a  diet  rich  in  car- 
bohydrates, sometimes  of  fats,  but  poor  in  proteins.  The  increasing 
cost  of  food  stuffs  renders  the  supplying  of  food  rich  in  protein  diffi- 
cult and  probably  the  use  of  whole  meal  will  be  found  to  solve  the 
problem.  Goldberger  advises  the  use  of  dried,  "not  canned,"  beans 
and  peas  during  the  winter  and  of  the  fresh  ones  during  the  summer. 

The  cure  of  the  disease  consists  of  placing  the  patient  upon  a 
diet  rich  in  proteins  and  vitamins  and  low  in  fats  and  carbohydrates, 
and  following  the  suggestion  of  Wood,  the  use  of  the  whole  meal 
or  even  of  the  fresh  corn  chops,  if  obtainable,  fresh  meat,  eggs,  beans 
and  peas  and  fresh  vegetables  should  go  to  make  up  a  great  part  of 
the  diet  and  the  carbohydrates  should  be  supplied  in  the  form  of 
breads  made  from  whole  wheat  or  whole  corn  flour.  See  anti-defi- 
eieney  Diet  under  Beriberi. 

UNCLASSIFIED  DISEASES 

ACIDOSIS 

After  reviewing  the  contributions  of  the  past  few  years  one  is 
tempted  to  paraphrase  Pilate's  question  and  ask  "What  is  acidosis?" 
Henderson  has  described  acidosis  as  any  disturbance  of  the  acid-base 
equilibrium  whereby  the  power  to  resist  the  acids  in  the  body  is  lost. 
The  metabolic  processes  are  attended  by  acid  formation  and  the 
equilibrium  is  maintained  by  the  excretion  of  carbon  dioxid  through 
the  lungs,  by  the  excretion  of  acid  by  the  kidney,  by  the  blood  having 
the  power  to  have  a  certain  amount  of  acid  added  to  it  without  having 
the  H  ion  concentration  much  changed  and  by  the  power  of  the 
body  to  form  ammonia,  which  helps  to  neutralize  the  acids  that  are 
formed. 

The  condition  of  acidosis  may  be  studied  in  many  ways,  but  most 
of  the  methods  are  as  yet  in  the  observation  stage  and  also  require 
a  great  deal  of  technical  training  as  well  as  laboratory'  facilities,  so 
they  are  not  available  to  the  average  practitioner.  The  CO2  tension 
in  the  alveolar  air  is  one  method  that  gives  satisfactory  evidence  as 
to  the  patient's  condition.  Various  methods  of  estimating  this  are 
in  use  and  the  normal  set  at  between  39  and  45  in  moderate  grades  of 
acidosis  and  it  may  fall  to  30,  and  in  the  severe  and  fatal  cases  it  may 
be  between  15  and  30  or  lower.  An  account  of  the  various  methods 
of  making  these  tests  and  much  other  information  on  acidosis  will 


UNCLASSIFIED  DISEASES  671 

be  found  iu  the  Transactions  of  the  American  Association  of  Phy- 
sicians for  1916,  and  the  references  therein.  Sellards  has  suggested 
a  simple  method,  that  of  giving  the  patient  sodium  bicarbonate  by 
mouth  and  noting  the  amount  necessary  to  turn  the  urine  alkaline  to 
litmus  paper.  In  using  this  test  5  grams  are  given  and  at  the  end 
of  two  hours  the  patient  voids  and  if  the  urine  is  still  acid  the  dose 
is  repeated.  If  the  patient  is  unable  to  void  the  next  dose  is  put 
off  until  after  the  next  urination  and  if  the  test  is  carried  on  into 
the  night  the  patient  is  not  aroused.  It  generally  takes  from  5  to 
15  grams  to  change  the  reaction  of  a  normal  person's  urine  from 
acid  to  alkaline. 

A  person  with  an  acidosis  may  respond  differently  to  the  various 
tests  and  it  is  probable  that  the  underlying  cause  may  vary  greatly. 

The  relation  of  the  ammonia  nitrogen  to  the  total  nitrogen  ex- 
creted in  the  urine  is  often  studied,  but  as  Rowland  and  Marriott 
state,  a  relative  increase  in  the  ammonia  nitrogen  suggests  an  acidosis, 
but  needs  confirmation  with  other  tests. 

The  presence  of  the  acetone  bodies  in  the  urine  may  be  taken  as 
evidence  that  there  are  abnormal  acids  in  the  blood,  but  it  gives  no 
information  as  to  the  amount.  As  a  control  in  starvation  cures 
tests  for  acetone  and  diacetic  acid  may  furnish  information  of  prac- 
tical value,  but  presence  of  these  substances,  particularly  in  the  urine 
of  children,  is  of  such  common  occurrence  as  to  render  the  mere 
finding  them  present  of  little  or  no  value. 

Acidosis  is  found  in  a  great  many  dift'ereut  diseases  and  condi- 
tions. That  of  diabetes  is  considered  under  that  disease.  Among  the 
other  conditions  in  which  it  occurs  may  be  mentioned  Asiatic  cholera 
and  the  severer  diarrheas  of  infancy,  the  cyclic  vomiting  of  children, 
'in  diseases  of  the  heart  and  kidneys,  and  the  combined  renal  and 
cardiac  diseases,  in  cachectic  states  and  the  severe  anemias,  in  preg- 
nancy and  eclampsia,  in  post-operative  shock  and  after  the  adminis- 
tration of  anesthetics  and  in  certain  febrile  conditions. 

The  production  of  acidosis  may  be  outlined  as  follows :  When  pro- 
tein is  oxidized  the  sulphur  and  phosphorus  form  sulphuric  and 
phosphoric  acids.  These  are  ordinarily  neutralized  by  the  carbonates 
of  sodium,  potassium,  calcium  and  magnesium.  These  carbonates 
are  formed  from  the  salts  or  organic  acids  of  these  substances,  taken 
in  the  fruits  and  vegetables  of  the  food,  by  oxidation,  with  the  addi- 
tion of  water  and  carbon  dioxid,  the  latter  being  excreted  through  the 
lungs.  When  these  are  not  sufficient  the  ammonia  formed  in  the  body 
neutralizes  the  excess.  The  ammonia  is  formed  from  the  amino-acids 
in  the  liver  or  muscles  being  deaminized,  that  is,  the  amino  group, 
NH,,  is  split  off  and  changed  to  ammonia  and  ordinarily  this  unites 
with  w^ater  and  carbon  dioxid  to  form  urea  which  is  excreted  through 
the  kidney.  If,  however,  the  acids  are  in  excess,  ammonia  salts  are 
formed  which  are  also  excreted  in  the  urine  and  the  relation  of  the 


672  DIET  IX  DISEASE 

ammonia  nitrogen  to  the  urea  nitrogen  shows  the  amount  of  neutrali- 
zation by  ammonia  in  the  body.  An  excess  of  ammonia  in  the  urine 
does  not  necessarily  mean  an  acidosis,  but  when  it  is  present  other 
tests  may  be  used  to  determine  the  condition.  In  pathologic  condi- 
tions the  acids  may  be  present  in  very  large  quantities  together  with 
organic  acids,  as  diacetic  and  oxybutj^ric,  formed  from  the  incomplete 
metabolism  of  the  fats,  and  these  may  be  in  excess  of  the  power  of 
the  body  to  neutralize  them  and  a  condition  of  acidosis  may  be  pro- 
duced. 

Post=operative  and  Post=anesthetic  Acidosis. — Some  of  these 
cases  ma}^  be  due  to  post-operative  shock,  but  the  majority  are  caused 
by  the  administration  of  the  anesthetic.  Ross  and  Hawk  found  that 
in  dogs  that  those  on  a  mixed  diet  did  not  develop  any  glycosuria 
after  anesthetic,  while  those  on  a  carbohydrate-free  diet  did.  It 
is  a  well  known  fact  that  children  and  adults  that  are  subject  to 
acidosis  are  prone  to  develop  it  after  the  administration  of  an 
anesthetic  and  that  the  condition  not  infrequently  proves  fatal. 
This  may  in  almost  all  cases  be  prevented  by  proper  prophylactic 
diet,  which  consists  of  reducing  the  fats  to  a  minimum  and  adding 
additional  carbohydrate  to  the  diet,  preferably  in  the  form  of  sugar. 
Some  advise  the  use  of  several  doses  of  a  10  per  cent,  glucose  solution 
several  times  a  day  for  three  days  before  the  operation.  "We  have 
had  extremely  satisfactory  results  from  the  use  of  cane  sugar,  either 
in  the  form  of  lump  sugar  or  of  candy,  so  that  we  have  never  tried 
the  glucose  as  a  prophylactic.  For  two  or  three  days  prior  to  the 
operation  the  patient  should  have  sufficient  bicarbonate  of  soda  to 
keep  the  urine  alkaline.  It  takes  from  5  to  15  grams  a  day  to  do 
this  with  an  adult,  and,  occasionally,  more. 

If  the  acidosis  develops  in  the  patient  large  quantities  of  sodium 
bicarbonate  should  be  given  by  mouth,  rectum  or  intravenously,  as 
the  condition  of  the  patient  permits.  "VVe  use  in  children  from  5 
grains  up  by  mouth,  dissolved  in  a  little  cold  water,  and  this  is  re- 
peated every  two  hours.  By  rectum  four  or  five  times  this  amount 
may  be  given  every  four  or  every  five  or  six  hours  in  150  to  200 
grams  of  water,  or,  better,  it  may  be  given  by  the  drip  method.  This 
may  be  dissolved  in  5  or  10  per  cent,  solution  of  glucose.  Glucose  may 
be  given  intravenously,  but  there  is  some  dift'erence  of  opinion  con- 
cerning its  value. 

Dunn  suggests  that  in  infants  the  glucose  solutions  injections  may 
be  made  into  the  longitudinal  sinus  or  into  one  of  the  cervical  veins 
if  any  are  large  enough.  The  procedure  is  simple,  but  sinus  injec- 
tions should  not  be  attempted  by  any  one  not  having  had  a  pretty 
large  experience  at  giving  intravenous  injections.  A  small  sized 
needle  is  connected  to  a  syringe  by  rubber  tubing  with  a  small  piece 
of  glass  tubing  just  above  the  needle.  The  whole  apparatus  is  steril- 
ized and  filled  with  sterile  solution.     Three  people  are  necessary.     One 


UNCLAISISIFIED  DIHEAISEIS  673 

to  hold  the  head  still,  the  second  introduces  the  needle  and  the  third 
manages  the  syringe.  After  the  needle  is  introduced  the  piston  of 
the  syringe  is  withdrawn  until  the  blood  is  seen  in  the  glass  tubing 
and  then  the  solution  is  slowly  injected.  If  the  solution  is  injected 
too  rapidl}'  the  veins  of  the  scalp  swell.  Not  over  150  c.c.  should  be 
given  at  one  time. 

The  intravenous  use  of  sodium  bicarbonate  is  not  without  danger, 
as  if  it  is  in  the  blood  in  too  concentrated  solution  it  may  cause  the 
blood  to  jell.  In  the  very  severe  cases  the  danger  of  death  may  be 
so  great  as  to  outweigh  this  possibility,  but  it  shows  that  it  must  be 
used  with  caution.  From  a  2  to  4  per  cent,  solution  is  used.  In 
infants  not  over  150  c.c.  should  be  given  at  one  time  lest  the  circula- 
tion be  over  burdened.  A  cervical  vein,  if  there  is  one  large  enough, 
or  if  the  operator  is  very  skilled  it  may  be  injected  into  the  longi- 
tudinal sinus  as  described  in  the  administration  of  glucose  solution. 
In  adults  from  500  to  1000  c.c.  may  be  given  very  slowly.  This  may 
be  repeated  within  eight  hours  if  necessary. 

Other  Forms  (See  also  Cyclic  Vomiting). — A  very  severe  and 
dangerous  form  is  sometimes  seen  in  severe  diarrheas,  especially  of 
the  cholera  infantum  type.     These  are  also  treated  as  the  above. 

Intraperitoneal  injections  of  sodium  bicarbonate  solution  may 
also  be  used  if  the  patient  is  in  a  hospital  where  a  proper  teehnic 
may  be  observed.     Great  care  is  needed  to  prevent  infection. 

Transfusion  from  an  alkalinized  donor  has  been  suggested  and 
carried  out  by  Gettler  and  Lindeman  (Journal  of  the  American 
Medical  Association,  February  24,  1917,  p.  591).  The  blood  of  the 
donor  and  the  recipient  must  be  compatible  and  the  donor's  blood 
alkalinized  by  the  administration  of  sodium  bicarbonate. 

CANCER  AND  DEMINERALIZED  FOOD 

Horace  Packard  (Boston  ^ledical  and  Surgical  Journal,  ^Nlareh  21, 
1912,  p.  452)  has  called  attention  to  a  point  which  is  well  worthy  of 
study,  and  that  is  that  the  great  increase  in  cancer  has  apparently 
followed  the  use  of  foods  which  have  been  more  or  less  demineralized, 
and  that  by  living  upon  such  foods  the  resistance  to  cancer,  whatever 
the  nature  of  it  may  be,  is  greatly  diminished.  The  foods  which  have 
thus  been  robbed  of  a  very  essential  part  are  wheat  or,  in  countries 
where  rice  is  extensively  used,  rice;  the  outer  surface  of  both  grains 
being  removed,  there  is  left  chiefly  a  residue  of  starch.  Potatoes 
peeled  and  cooked  by  boiling  lose  perhaps  50  per  cent,  of  their  min- 
eral content.  Packard,  having  this  theorv  of  mineral  starvation  in 
mind,  has  been  giving  to  some  of  his  inoperable  recurrent  cancer 
cases  a  diet  rich  in  minerals,  and  has  found  apparently  an  arrest  of 
the  disease  and  a  general  condition  of  good  health  quite  at  v'arianee 
with  former  experiences  in  similar  cases.  His  dietary  is  as  follows : 
(1)   Exclude  all  white  flour  bread,  and  all  articles  into  which  white 


674  DIET  IN  DISEASE  — ^ 

flour  enters,  and  substitute  bread  made  from  whole  wheat  flour. 
There  are  whole  wheat  flours  on  the  market  which  are  finely  milled 
and  which  are  satisfactory. 

(2)  Potatoes,  next  to  bread,  form  the  most  important  and  widely 
used  article  of  diet,  and  properly  conserved  in  cooking  they  are  rich 
in  the  food  salts,  which  are  located  in  the  peripheral  portion  imme- 
diately beneath  the  skin.  Therefore,  one  or  two  baked  potatoes  daily 
are  advised,  prepared  as  follows:  Discard  the  heart  or  central 
starchy  portion  and  eat  the  peripheral  portions  rich  in  mineral  in- 
gredients, conser\ang  to  the  very  outer  skin.  The  common  way  of 
cooking  potatoes  by  paring  raw,  soaking  in  cold  water  for  an  hour  or 
two,  then  boiling,  dissolves  out  and  boils  out  about  50  per  cent,  of 
the  food  salts. 

(3)  Encourage  the  eating  freely  of  well-cooked  fresh  vegetables, 
apples  raw  or  cooked  in  any  way,  and  fresh  ripe  fruits. 

(4)  Meats  and  fish  may  be  used  moderately,  according  to  inclina- 
tion, bearing  in  mind  that  these  probably  make  no  difference  one  way 
or  the  other  in  the  development  or  growth  of  cancer.  Flesh  foods, 
as  consumed  by  the  human  family,  are  relatively  poor  in  the  food 
salts,  and  at  best  the  elements  of  such  food  reach  us  second  hand  and 
constitute  a  very  poorly  balanced  article  of  diet,  in  that  we  consume 
almost  exclusively  the  muscle  tissue,  thus  getting  none  of  the  food 
salts  stored  in  the  nerves,  bones,  and  other  structures. 

A  normal  amount  of  protein  must  be  included  in  the  dietary,  and 
if  not  taken  as  flesh  food  or  in  vegetables,  it  must  be  made  up  in  eggs, 
cheese,  milk,  and  leguminous  vegetables. 

Bulkley,  at  the  New  York  Skin  and  Cancer  Hospital,  suggests  the 
following  vegetarian  diet  with  a  minimum  of  protein.  The  following 
menus  average  about  2100  calories  per  day. 

FIRST  DAY 

Breakfast  Dinner 

4  ounces  Rice  5  ounces  Vegetable  soup 

3  "       Corn  bread  3        "       Baked  potatoes 
1^      "       Butter  3        "       Stewed  celery 

i        "       Sugar  1        "       Graham  bread 

Hot  water  II      "       Butter 

1   Fresh  apple 

Supper 
4  ounces  Rolled  oats 
2        "       White  bread 
U      "       Butter 
4        "       Stewed  prunes 
i        "       Sugar 
Very  weak  tea 

SECOND  DAY 
Breakfast  Dinner 

Orange  5  ounces  Pea  soup 

4  ounces  Hominy  3        "       Macaroni 

2        "       Graham  toast  3        "       String  beans 


UNCLAISISIFJED  DliSEAISEIS 


675 


Breakfast 
li  ounces  Butter 
i        "       Sugar 
Postum 

Supper 

Dhiner 
3  ounces  Carrots 
2        "       Bread 
1^      '•       Butter 
Dates 

4  ounces  t'ream  of  Wheat 
2        "       Graham  toast 
li      "       Baked  apple 
2        "       Crackers 
U      "       Butter 
.   i        "       Sugar 
Very  weak   tea 

Breakfast 

THIRD  DAY 

Dinner 

Banana 
4  ounces  Petti  John 
2        •'       White  bread 
U      "       Butter 
i        "       Sugar 

Hot  water 

^  ounces  Corn  soup 
3        "       Baked  potatoes 
3        "       Spinach 
3        "       Boiled  onions 
2        "       Bread 
1^      "       Butter 
Raisins 

Supper 

4  ounces  Farina 
4        "       Stewed  figs 
2        "       Graham  crackers 
U      "       Butter 
i        "       Sugar 
Very  weak  tea 

FOURTH  DAY 
Breakfast 
Raw  apple 
4  ounces  Cornmeal  mush 
2        ■'       Graham  bread 
li      "       Butter 
i        "       Sugar 
Poxtum 

Dinner 
5  ounces  Vegetable  soup 
4        "       Baked  beans 
3        "       Cauliflower 
3        "       Asparagus 
2        "       Bread 

li        "         Rut.tpr 

Orange 


Supper 
4  ounces  Rice 
4        "       Stewed  prunes 
2        "       Graham  crackers 
li      "       Butter 
i        "       Sugar 
Very  weak  tea 


Breakfast 

Orange 
4  ounces  Cracked  wheat 
3        "       Corn  muffins 
U      "       Butter 
i        "      Sugar 

Hot  water 


FIFTH 

DAY 

Dinner 

5 
4 
3 

3 
U 

ounces 

a 

n 

Sago  soup 
Spaghetti 
Lima  beans 
Boiled  onior 
Butter 

Dates 


Supper 
4  ounces  Cream  of  Wheat 
Sliced  orange 
2  ounces  Oatmeal  crackers- 


676  DIET  IX  DISEASE 


1]  ounces  Butter 

i       "       Sugar 

Very  weak  tea 

SIXTH  DAY 

Breakfast 

Dinner 

4  ounces  Samp 

5  ounces 

Celery  soup 

2        "       Graham  toast 

4 

Baked  potatoes 

U      "       Butter 

3 

Carrots 

i        "       Sugar 

3 

Spinach 

Postum 

U     " 

Butter 

2 

Bread 

Figs 

Supper 

4  ounces  Wheatena 

4        "       Stewed  figs 

2        "       Uneeda  biscuit 

li      "       Butter 

i        "       Sugar 

Very  weak  tea 

Repeat  this  bill  of  fare  on  successive  days. 

Some  interchange  of  the  different  articles  may  be  made,  to  suit  the  appetite  or 
convenience  of  patients;  but  in  the  main  this  bill  of  fare  should  be  followed. 

Bread  at  least  24  hours  old  may  be  taken  as  desired. 

A  little  old  cheese  may  be  grated  on  the  macaroni  and  spaghetti,  but  not  cooked 
with  it. 

One  boiled  or  poached  egg  may  be  taken  for  breakfast  every  other  day,  and  very 
fat  bacon  on  the  alternate  days,  unless  otherwise  directed  by  the  physician. 

It  is  desirable  to  eat  the  skin  of  potatoes. 

Each  and  every  meal  should  be  eaten  very  slowly,  for  half  an  hour,  witli  long 
chewing. 

One  tumbler  of  water  is  to  be  taken  with  eacli  meal,  but  not  when  food  is  in 
the  mouth ;  also  a  tumbler  full  of  hot  water,  one  hour  before  breakfast  and  supper. 

No  milk  is  to  be  taken  unless  specially  ordered. 

The  cereals  are  to  be  boiled  with  water,  three  or  four  hours,  and  may  be  cooked 
in  the  afternoon  and  heated  in  the  morning,  adding  more  water.  I'ice  farina  and 
Cream  of  Wheat  require  only  one  hour.  Chopped  dates,  figs,  raisins,  or  currants 
may  be  added  to  cereals  when  desired. 

AH  the  cereals  are  to  be  served  very  hot,  on  hot  plates,  and  eaten  with  butter 
and  salt  to  taste  (not  milk  and  sugar).  They  are  to  be  eaten  very  slowly,  with  a 
fork,  and  very  well  chewed. 

The  crackers  with  supper  may  be  varied  to  suit  the  taste,  they  should  be  eaten 
dry,  with  butter,  and  chewed  very  thoroughly. 

Nothing  should  be  taken  between  meals,  unless  especially  directed,  and  the 
life  should  be  as  simple  and  healthful  as  possible,  with  early  and  long  bed  hours. 

DUCTLESS  GLANDS,  TUMORS  AND  DIET 

Sweet,  Corson-White  and  Saxon  have  made  some  studies  on  the 
transplantable  tumors  of  rats  and  mice  and  they  suggest  a  possibly 
fruitful  field  in  dietetic  research.  Some  years  ago  Hunt,  as  noticed 
in  the  preface  of  our  fourth  edition,  showed  hy  experiments  on 
animals  that  certain  diets  had  specific  effects  on  the  thyroid  gland 
in  some  of  the  lower  animals.  The  investigators  just  referred  to 
found  that  the  tumors  could  be  influenced  in  their  rate  of  growth  by 
changing  the  diet,  making  the  tumors  g'row  either  fast  or  slow,  ac- 
cording to  the  nature  of  the  feeding.     It  was  also  found  that  castra- 


UyCLASSlFIED  DIlSEAiSEti  677 

tion  of  the  male  renders  the  animal  more  receptive  of  the  transplant 
and  the  rate  of  growth  is  increased. 

This  suggests  that  study  of  tliets  in  human  cancer  might  show- 
that  foods  exert  an  influence  for  good  or  bad  through  their  acting 

upon  the  glands. 

EXOPHTHALMIC  GOITER 

Any  tendency  to  constipation  should  be  relieved  promptly.  Foods 
that  are  apt  to  cause  flatulency  {q.  v.)  should  be  avoided. 

The  metabolism  of  these  patients  is  very  greatly  increased  so  that 
a  patient  at  rest  may  have  requirements  of  a  person  at  hard  labor. 
The  nitrogen  equilibrium  is  maintained  with  difficulty  and  the  body 
wastes  rapidly.  There  may  be  alimentary  glycosuria.  There  is  a  loss 
of  phosphorous  through  the  intestines  and  the  amount  of  calcium 
excreted  in  the  feces  is  increased.  DuBois  states  that  there  is  no 
indication  against  the  use  of  fairly  large  amounts  of  protein  and 
there  is  no  reason  to  prefer  the  protein  of  milk  to  that  of  meats.  As 
regards  quantity  a  patient  with  Graves'  disease  needs  one  and  a 
half  to  twice  as  much  food  as  an  ordinary  individual  of  the  same 
weight. 

Tea,  coffee,  and  tobacco  should  be  abstained  from,  or,  if  the  patient 
refuses  to  do  this,  their  use  limited  to  the  smallest  possible  amount. 
Alcohol  should  be  prohibited,  except  in  habitues,  when  sudden  with- 
drawal may  cause  great  cardiac  weakness. 

ADDISON'S  DISEASE 

So  long  as  the  digestion  is  not  seriously  impaired  a  mixed  diet,  of 
as  nutritious  a  mixture  as  possible,  should  be  given.  ^lilk  and  cream, 
fresh  meat,  fish,  oysters,  well-cooked  vegetables,  and  farinaceous  food 
may  be  used.  Good  wanes  or  spirituous  liquors  may  be  allowed  in 
small  quantities  if  desired,  or  when  needed  as  either  a  tonic  or  a 
stimulant. 

"When  gastric  irritability  occurs,  the  treatment  is  the  same  as  that 
for  nervous  vomiting — liquid,  even  predigested,  food  should  be  given 
in  small  quantities  (see  Nervous  Vomiting  and  Feeding  after  Lapa- 
rotomies). In  some  cases  a  mixture  of  two  parts  of  lime-water  and 
one  part  of  milk  may  be  used  with  advantage.  If  this  is  not  retained, 
teaspoonful  doses,  given  regularly  every  fifteen  minutes,  may  be  tried. 
In  the  worst  cases  rectal  feeding  may  be  instituted  for  several  days, 
thus  giving  the  stomach  a  complete  rest. 

When  the  patient  becomes  weakened,  even  when  no  special  gastric 
symptoms  exist,  it  is  well  to  give  food  at  short  and  regular  intervals. 
Liquid  and  predigested  food,  together  with  milk,  custards,  egg-nog, 
sherry  and  egg,  broths,  and  gruels  are  to  be  ordered. 

OSTEOMALACIA 

As  nutritious  and  as  generous  a  diet  as  the  patient   can  digest 


678  DIET  1^  DISEASE  \ 

should  be  given.  It  has  been  recommended  that  an  abundance  of 
salts  be  taken.  Phosphates  and  hypophosphites  with  cod-liver  oil  are 
perhaps  the  best  means  of  supplying  salts  to  the  system.  The  disease 
requires  further  study. 

DIET  IN  DISEASES  OF  THE  SKIN 

Certain  skin  affections  are  caused  directlj^  or  indirectly  by  dietary 
errors;  others  are  prolonged  or  intensified  bj-  an  improper  diet,  and 
still  others  are  connected  in  some  way  with  diseases  of  the  alimentary 
tract  or  with  disturbed  metabolism. 

The  belief  that  skin  diseases  are  caused  by  improper  food  is  very 
prevalent  among  the  laity,  and  the  effect  of  diet  on  the  skin  is  often 
overestimated  because  of  the  common  habit,  which  some  physicians 
have,  of  ascribing  almost  all  skin  lesions  to  a  disordered  stomach. 

Certain  foods  may  cause  skin  lesions,  usually  of  the  urticarial  type, 
in  from  a  few  minutes  to  several  days  after  ingestion.  This  is  evi- 
dently, in  some  cases,  the  result  of  reflex  action ;  in  others,  of  toxic 
substances  in  the  food.  These  lesions  are  usually,  though  not  always, 
dependent  on  idiosyncrasy.  Brocq  held  that  skin  diseases  may  be 
engendered  by  the  prolonged  use  of  certain  foods,  and  maintained 
that  the  disease  might  only  appear  years  later.  This  has  never  been 
proved,  and  therefore  requires  no  discussion. 

In  such  metabolic  diseases  as  gout  and  diabetes  the  existence  of 
some  of  the  lesions  may  be  explained  on  the  ground  that  irritating 
abnormal  by-products  are  excreted  together  with  the  sweat. 

Certain  poisons  taken  in  with  the  food  may  give  rise  to  conditions 
in  which  skin  manifestations  play  an  important  part.  In  this  con- 
nection may  be  mentioned  ergotism  and  pellagra.  Alcohol  and  "top- 
er's nose"  (acne  rosacea)  are  commonlj-  coupled  in  the  mind,  al- 
though the  latter  may  occur  in  individuals  who  have  never  used 
alcohol. 

The  suggestions  which  follow  for  the  dietetic  management  of  eczema 
may  be  employed  with  advantage  in  the  treatment  of  most  curable 
skin  diseases,  as  it  consists  chiefly  in  getting  the  patient  into  the  best 
possible  physical  condition. 

The  Use  of  Milk  in  Certain  Skin  Diseases. — Bulkley  has  called 
attention  to  the  idea  of  giving  milk  alone,  either  pure  or  diluted  with 
boiling  water  at  the  body  temperature,  just  after  the  alkaline  tide 
has  set  in,  or  during  its  continuance,  to  avoid  food  or  any  substance 
that  could  call  forth  gastric  secretion  until  after  its  absorption  has 
been  fully  accomplished.  The  milk  should  have  nothing  whatever 
added  to  it,  neither  whisky  nor  egg,  and  the  eating  of  anything  with 
the  milk  should  be  forbidden.  In  order  to  be  sure  that  the  stomach 
is  in  an  alkaline  condition,  the  milk  is  better  given  an  hour  or  even 
thirty  minutes  before  the  next  meal  time;  and  sometimes  it  is  of  ad- 


DISEASES  OF  THE  SKIN  67!) 

vantage  to  give  bicarbonate  of  soda  in  full  doses  half  an  hour  or  so 
before  taking-  the  milk,  or  the  milk  may  be  rendered  distinctly  al- 
kaline by  the  addition  of  bicarbonate  of  soda.  The  milk  should  not 
be  over  100°  F.,  and  should  not  be  too  rich  in  fat.  Given  at  that  time 
milk  is  often  well  borne,  and  in  individuals  who  otherwise  would  not 
be  able  to  take  it,  the  additional  nourishment  causes  gain  in  weight, 
and  may  be  used  with  benefit  in  cases  of  acne,  eczema,  and  psoriasis, 
especially  in  the  more  chronic  form. 

ECZEMA 
The  diet  of  both  acute  and  chronic  eczema  is  important.  In  gen- 
eral it  may  be  stated  that  the  prophylaxis  in  predisposed  individuals 
consists  in  a  simple  varied  diet,  and  the  avoidance  of  such  articles 
of  food  as  are  known  to  cause  attacks  of  erythema  or  urticaria  in  the 
patient  under  treatment.  It  should  be  remembered  that  one  patient 
will  eat  with  impunity  a  food  that  will  poison  another.  (See  Urti- 
caria.) In  addition,  anything  known  to  cause  intestinal  disturbance 
or  indigestion  should  be  avoided. 

When  eczema  is  present,  the  indications  are  to  avoid  indigestion 
and  disturbances  of  the  stomach  and  bowels.  In  the  gouty  the  diet 
should  be  regulated  according  to  the  suggestions  laid  down  for  the 
manag-ement  of  gout.  Other  coexisting  diseases  should  also  be  con- 
sidered from  a  dietetic  standpoint. 

The  habits  of  the  patient  should  carefully  be  considered.  If  the 
nutrition  is  below  normal,  eft'orts  should  be  made  to  improve  it  by 
means  of  nourishing  food,  such  as  milk,  eggs,  and  meat.  If,  as  is 
more  often  the  case,  the  patient  overeats  or  is  obese,  the  diet  should 
be  restricted.  The  patient  should  avoid  all  indigestible  articles,  and 
partake  of  a  diet  varied  according  to  his  taste,  but  reduced  in  quan- 
tity. Alcoholic  drinks  of  all  kinds  should,  as  a  rule,  be  prohibited, 
and  cotfee  and  tea  taken  in  great  moderation,  if  at  all.  In  obese 
patients  careful  regulation  of  the  diet  according  to  one  of  the  methods 
described  in  the  treatment  of  obesity  will  usually  answer  the  purpose. 

When  the  disease  is  due  to  indigestion,  the  result  of  improper  feed- 
ing, the  diet  should  be  regulated  according  to  the  form  of  disease 
present.  All  indigestible  and  fried  foods,  pickles,  and  strongly  sea- 
soned or  very  rich  foods  should  be  avoided.  The  digestion  is  often 
disturbed,  particularly  in  women,  by  over-indulgence  in  sweets  and 
pastry,  especially  at  wrong  hours.  In  all  cases  the  food  should  be 
plain,  well  cooked,  and  taken  at  regular  intervals,  no  solid  food  being 
allowed  between  meals. 

Schweninger  recommends  in  some  eases  smaller  meals  than  are  ordi- 
narily taken,  at  shorter  intervals;  in  others,  that  the  meal  shall 
consist  of  but  one  or  two  dishes. 

In  the  very  severe  acute  or  persistent  forms,  an  absolute  milk  diet 
or  a  diet  composed  largely  of  milk  should  be  prescribed.  (See  Milk 
Cure.) 


680  DIET  IN  DISEASE 

Eczema  in  Infants. — If  the  child  is  nursing,  the  milk  should  be 
examined,  and  if,  as  is  usually  the  case,  the  milk  is  found  to  be  very 
rich  and  the  baby  is  fat  and  well  nourished,  an  attempt  should  be 
made  to  reduce  the  amount  of  fat  in  the  mother's  milk  according  to 
the  directions  given  in  the  section  on  Infant  Feeding.  Malt  and  al- 
coholic liquors  of  all  kinds  should  be  forbidden,  and  the  amount  of 
meat  ingested  should  be  reduced  and  exercise  increased. 

In  some  cases,  where  the  proteins  are  at  fault,  the  child  suffers  from 
indigestion  and  colic  and  curds  are  found  in  the  stools.  The  child 
usually,  although  not  always,  appears  to  be  well  nourished.  The 
amount  of  food  given  the  infant  should  be  lessened,  either  by  shorten- 
ing the  time  the  infant  nurses  or  by  lengthening  the  intervals.  The 
child  should  be  urged  to  take  water  between  the  nursings ;  an  alkaline 
water,  such  as  Vichy,  will  be  found  of  value.  If  the  child  is  thin  and 
poorly  nourished,  fat  in  addition  to  that  contained  in  the  milk 
should  be  given.  Cream  or  cod-liver  oil  may  be  used  for  this  pur- 
pose. This  is  not  advisable  in  fat,  well-nourished  infants,  for  in 
them  the  disease  may  be  due  to  an  excess  of  fat  in  the  food. 

In  artificially  fed  infants  Holt  advises  giving  first  a  food  moder- 
ately high  in  fat  and  low  in  protein,  and  then,  if  the  desired  effect  is 
not  produced,  a  milk  low  in  fat  and  protein. 

Bulkley,  from  many  years'  experience,  is  convinced  of  the  value  of 
wheat  jelly.  His  directions  for  preparing  and  using  it  are  as  fol- 
lows: 

"The  wheat  jelly  is  prepared  in  the  following  manner:  about  one 
cupful  of  the  crushed  wheat  is  placed  in  a  pint  or  more  of  cold 
water,  in  a  china  double  boiler,  and  put  on  the  fire.  This  is  allowed 
to  boil  for  four  hours,  when  it  is  set  aside,  covered  up,  until  the  next 
day.  More  water  is  then  added,  with  stirring,  and  it  is  again  boiled 
from  two  to  three  hours,  more  water  being  added  as  necessary,  to 
make  a  soft  mass.  This  mass  is  then  placed  in  a  very  fine  sieve  and 
is  rubbed  through  it,  with  the  bowl  of  a  spoon,  until  no  more  will 
pass  through,  and  the  resulting  wheat  jelly  is  scraped  off  for  use 
during  the  day,  it  being  freshly  prepared  daily.  One  to  three  or  four 
teaspoonfuls  of  this  is  used  at  each  feeding,  according  to  the  age  of 
the  child  and  the  requirements  of  the  case :  sometimes  it  proves  quite 
laxative.  Prepared  in  this  way  it  makes  a  soft,  pleasant  jelly  which 
mixes  readily  with  the  milk  ana  passes  through  a  feeding  nipple: 
in  some  instances  it  is  desirable  to  give  it  alone,  in  a  spoon,  slightly 
salted,  and  a  little  sweetened  with  sugar  of  milk." 

The  jelly  does  not  keep  very  well  and  should  always  be  made  fresh 
every  day. 

What  has  been  said  of  the  treatment  of  adults  applies  as  well  to 
older  children.  In  the  latter  the  disease  is  generally  due  to  the  exces- 
sive use  of  starches  or  sugars.  Pickles  and  indigestible  cold  lunches 
may  be   the   cause   of  this   condition   in   school-children.     The    diet 


DISEASES  OF  THE  SKIN  681 

should  be  regulated  according  to  the  rules  given,  and  if  the  disease 
still  persists,  a  milk  diet  may  be  tried.  The  drinking  of  water 
between  meals  is  often  of  value. 

URTICARIA 

The  first  step  in  the  treatment  of  urticaria  is  to  secure  free  evacua- 
tion of  the  bowels.  For  this  purpose  an  active  saline,  such  as  sul- 
phate of  magnesia,  should  be  given.  Following  this,  the  diet  should 
be  very  simple  until  the  urticaria  has  disappeared.  Preferably  a 
milk  diet  should  be  given,  lime-water  or  an  ett'ervescing  water  being 
added  to  the  milk  if  necessary;  if  there  is  indigestion,  the  milk  may 
be  peptonized.  When  there  is  a  diminution  in  the  quantity  of  urine 
excreted,  alkaline  diuretics  may  be  prescribed  or  Vichy  water  may  be 
drunk  freely. 

In  many  individuals  the  attacks  are  brought  on  by  certain  articles 
of  diet.  "What  these  are  may  generally  be  determined  by  careful  ob- 
servation. Oysters,  crabs,  and  other  shellfish  are  a  frequent  cause. 
These  and  other  articles  of  diet,  if  they  are  not  fresh  or  are  beginning 
to  spoil,  are  also  frequently  responsible  for  this  disturbance.  Straw- 
berries produce  a  red  rash  of  an  urticarial  nature  in  many  persons. 
AVhen  the  offending  article  has  been  discovered,  it  shovild  be  eliminated 
from  the  dietary. 

ACNE 

In  certain  persons  acne  may  be  overcome  by  careful  dieting.  In 
some,  special  articles  of  diet,  such  as  buckwheat  cakes  and  other  fried 
foods,  greasy  doughnuts,  rich  pies  and  cakes,  and,  in  fact,  almost  any 
indigestible  article  of  diet,  have  been  held  responsible  for  the 
disease. 

In  giving  directions  regarding  the  diet  it  is  well  to  prohibit  all 
indigestible  foods,  such  as  those  just  mentioned,  and  to  prescribe 
a  substantial  varied  diet  of  fresh  food  of  the  more  easily  digestible 
kinds.  In  the  severe  and  resistant  cases  a  milk  diet  may  be  tried,  and 
Moser  and  Pieper  suggest  that  milk  be  skimmed  to  remove  the  most  of 
the  fat.  Bulkley  forbids  fats,  butter,  alcohol,  smoked  meats,  and 
many  other  articles  of  diet.  Other  authors  interdict  tea,  coffee, 
cheese,  fish,  and  a  host  of  other  foods  have  been  named  as  injurious. 

The  bowels  should  be  regulated,  and  hot  water  or  Vichy  taken  freely 
between  meals.  Careful  dietary  studies  made  in  connection  with  acne 
might  prove  of  considerable  value. 

ACNE  ROSACEA 

As  has  been  said  elsewhere,  this  is  generally  coupled  in  the  minds 
of  the  laity  with  alcoholism.  Although  alcohol  is  often  a  causative 
factor,  the  disease  occurs  also  in  those  who  never  use  alcoholic  bever- 
ages. Jackson  maintains  that  the  use  of  large  quantities  of  strong 
tea  may  also  produce  it.     In  general  the  diet  should  be  bland  and  un- 


682  DIET  ly  DISEASE 

irritating.  Rich  and  highly  seasoned  food,  as  well  as  aicoho.,  should 
be  avoided.  Tea  and  coffee,  if  used  at  all,  should  be  taken  in  small 
quantities  and  not  too  strong.  The  diet  should  be  similar  to  that 
prescribed  for  eczema.  Many  of  the  patients,  it  will  be  found,  prefer 
the  'ileasures  of  the  table  to  a  possible  betterment  of  the  skin  disease. 

PSORIASIS 

Diet  is  apparently  of  little  value  in  the  treatment  of  this  condition. 
Many  authors  have  recommended  various  forms  of  diet,  but  in  general 
it  may  be  said  of  this,  as  of  other  skin  diseases,  that  the  diet  should 
be  such  as  the  general  condition  of  the  patient  demands.  If  the 
patient  is  thin  and  debilitated,  a  nourishing  diet  should  be  ordered, 
whereas  if  he  is  obese,  his  diet  should  be  restricted. 

Brocq  insisted  on  the  value  of  regulating  the  diet  of  patients  of 
gouty  families  according  to  the  lines  laid  down  in  the  section  on 
Gout.  Other  authors  recommend  that  the  use  of  coffee,  tea,  alcohol, 
and  tobacco  be  prohibited  in  nervous  individuals. 

Bulkley  is  a  firm  believer  in  the  value  of  a  vegetarian  diet  and 
believes  that  he  has  obtained  very  good  results  by  its  use  and 
attributes  a  failure  to  get  satisfactory  results  to  the  nonadherence 
to  the  diet.  A  strictly  vegetable  diet  may  be  tried,  or  what  will 
be  found  to  be  satisfiaetory  in  some  eases,  a  diet  with  a  mininnan  of 
protein.  This  subject  of  minimum  protein  diets  is  discussed  under 
the  heading  of  Nephritis. 

PRURITUS 

The  existence  of  gout,  diabetes,  and  diseases  of  the  liver,  kidney,  or 
alimentary  tract  should  be  definitely  determined,  and  if  such  disease 
is  found  to  exist,  the  diet  should  be  regulated  accordingly.  In  severe 
cases  a  milk  diet  may  be  ordered,  and  an  abundance  of  mineral  water 
between  meals  and  on  rising. 

All  irritating  articles  of  diet  should  be  avoided.  All  highly  sea- 
soned and  indigestible  dishes,  pepper,  especially  paprika,  spices,  and 
the  like,  should  not  be  used.  Brocq  advises  that  the  following  articles 
be  withheld:  tobacco,  alcohol,  tea.  coft'ee,  fish,  crabs,  sausage,  and 
cheese. 

FURUNCULOSIS 

There  is  no  special  diet  for  furunculosis.  The  general  nutrition 
should  be  improved  by  prescribing  a  varied  diet  of  well-prepared 
food.  If  there  is  disease  of  the  alimentary  tract,  the  diet  should  be 
such  as  is  indicated  in  that  disease.  If  diabetes  or  anemia  coexist, 
they  should  receive  attention. 


SPECIAL  DIETS 
THE  KARELL  DIET  OR  THE  MILK  CURE 

This  treatment  has  been  found  to  be  of  particular  value  in  the 
treatment  of  cardiac,  renal  and  hepatic  dropsies;  in  congestion, 
simple  hypertrophy,  and  fatty  conditions  of  the  liver;  in  various 
gastric  and  intestinal  disorders,  particularly  those  associated  with, 
defective  nutrition,  such  as  chronic  indigestion,  chronic  colitis,  and 
chronic  intestinal  neuralgia;  in  asthma  due  to  emphysema  or 
catarrhal  conditions ;  in  obesity ;  and  in  functional  nervous  conditions 
in  vs^hich  the  nutrition  is  greatly  lowered.  Karell  also  advocated  the 
milk  cure  in  organic  disease  of  the  heart  and  blood  vessels,  in  advanced 
kidney-  disease,  and  in  rheumatic  and  gouty  diseases. 

Karell  published  his  paper  in  1866  (Archives  General  de  Medecine, 
viii,  p.  513),  and  this  method  has  been  used  in  Russia  quite  exten- 
sively. It  was  introduced  into  Germany  with  great  slowness  and  in 
this  country,  Weir  Mitchell  was  one  of  the  chief  exponents.  It  does 
not,  however,  seem  to  have  attained  the  popularity  which  its  great 
usefulness  would  suggest.  The  cure  itself  is  exceedingly  simple.  It 
offers  no  difficulties  as  far  as  the  physician  himself  is  concerned.  The 
patient,  however,  may  need  a  very  considerable  amount  of  encourage- 
ment to  make  him  continue  the  diet,  which,  to  many,  becomes  exceed- 
ingly' irksome. 

The  patient  must  be  put  to  bed,  the  bowels  kept  open,  preferably 
by  saline  laxatives  or  enemata  or  rhubarb  or  castor  oil  may  be  used. 
Small  quantities  of  coffee  mixed  with  the  morning's  milk  later  on  in 
the  cure  and  the  use  of  stewed  prunes  or  baked  apples  in  the  after- 
noon are  also  useful  in  relieving  constipation,  but  are  not  used  in 
the  early  part  of  the  treatment.  Karell 's  method  was  to  give  the 
patient  200  c.c.  of  raw  or  boiled  milk,  taken  either  warm  or  cold, 
according  to  the  preference  of  tHe  patient  at  8  a.  m.,  12  m.,  4  p.  m.  and 
8  p.  M.  This  method  is  particularly  applicable  to  cases  with  dropsy 
or  the  other  conditions  mentioned. 

The  treatment  suggested  by  Mitchell  may  be  used  as  it  is  less 
disagreeable  to  the  patient.  At  the  beginning  no  other  food  or 
liquor  is  allowed.  During  the  first  few  days  thirst  may  be  very 
troublesome.  The  patient  may  be  allowed  to  rinse  his  mouth  with 
water,  but  must  not  swallow  any.  Occasionally  the  patient  will  com- 
plain of  hunger  and  if  this  is  very  marked  a  small  piece  of  dry  toast 
or  zwieback  may  be  given  with  each  glass  of  milk.  This  is  continued 
until  the  edema  begins  to  diminish.     When  this  occurs  the  diet  may 

683 


684:  DIET  IN  DISEASE 

be  increased,  ordinarily  a  week,  sometimes  more  may  pass  before 
the  patient  has  lost  a  sufficient  amount  of  fluid  to  be  justified  an 
increase  in  the  diet.  A  soft  boiled  egg,  without  anything  else,  may 
be  given  at  10  a.  m.  and  toast  or  zwieback  at  6  p.  m.  The  diet  is  then 
gradually  increased,  adding  small  amounts  of  salt-poor  foods  until 
the  patient  is  on  a  diet  suitable  for  his  condition.  The  foods  that  are 
suitable  for  patients  of  this  kind  are  meat,  fresh-water  fish,  fresh 
eggs,  thick  soups,  peas  and  string  beans,  rice,  corn,  and  hominy,  or 
other  cereals  and  the  other  foods  which  may  be  chosen  from  the  table 
showing  the  composition  of  foods  as  regards  sodium  chlorid,  given 
under  the  Salt-free  Diet. 

During  all  of  this  time  for  from  two  to  four  weeks  after  the  dis- 
appearance of  the  edema  the  fluid  should  be  kept  down  to  800  c.c. 

By  using  this  method  some  very  extraordinary  cures  or  improve- 
ments may  be  brought  about.  The  general  condition  of  the  patient 
improves,  nausea  and  vomiting  disappears,  the  patient  sleeps  better, 
has  not  so  much  dyspnea.  In  some  cases  it  is  necessary  to  use  digi- 
talis or  other  drugs  in  connection  with  heart  symptoms.  The  condi- 
tion of  the  heart  itself  usually  improves  greatly.  The  blood  pressure 
becomes  lower  and  the  patient  voids  large  ((uantities  of  urine.  The 
chlorid  output  is  usually  greater  than  the  intake  and  the  loss  of 
weight  may  be  extraordinary,  as  much  as  54  pounds  in  ten  days 
having  been  reported  by  Goodman,  and  in  this  ease  31  pounds  were 
lost  in  three  days. 

The  cure  seems  to  have  some  value  in  prognosis  and  Wittich  re- 
gards a  chlorid  equilibrium,  persistence  of  edema,  stationary  or 
diminishing  urine  output  as  all  of  serious  import.  A  positive  chlorid 
means  an  unfavorable  prognosis.  He  believes  if  after  the  patient  has 
taken  the  cure  and  there  is  a  return  of  salt  retention  the  cure  should 
be  repeated  before  there  is  a  break  in  the  compensation.  The  cure  is 
not  to  be  used  where  there  are  symptoms  of  uremia. 

In  the  other  conditions  mentioned  above  milk  may  be  given  accord- 
ing to  the  method  of  iVIitchell,  who  starts  with  four  ounces  of  milk 
every  two  hours,  gradually  increasing  the  dose  and  lengthening  the 
interval  to  three  hours.  He  also  prescribes  a  glass  at  night,  if  neces- 
sary, mixed  with  lime-water,  or,  later  in  the  cure,  mixed  with  one  of 
the  lactated  infant's  foods.  He  also  insists  on  the  necessity  for  pre- 
scribing rest  with  this  treatment. 

During  the  second  or  third  week,  if  there  is  an  irresistible  craving 
for  solid  food,  a  bit  of  stale  bread  with  salt  or  a  small  amount  of  salt 
herring  may  be  given.  Once  a  day  milk  soup,  thickened  with  a 
cereal,  may  be  given.  After  five  or  six  weeks  one  other  article  of 
food  may  be  allowed  for  dinner,  and  if  the  desired  effect  has  been 
produced,  a  gradual  return  may  be  made  to  an  ordinary  diet,  which 
should,  however,  still  contain  considerable  milk. 


SPECIAL  DIETS  685 

WHEY  CURE 

In  some  of  the  foreign  health  resorts  a  cure  somewhat  similar 
to  tile  milk  cure  has  been  employed,  and  consists  in  tlie  drinking,  at 
stated  intervals,  of  warm  whey  to  which  alkaline  mineral  waters  have 
been  added.  About  one  and  one-half  pints  are  taken  daily.  The 
amount  of  meat  taken  is  limited,  and  the  quantity  of  fruit  and 
vegetables  is  increased.  This  method  of  treatment  is  said  to  be  of 
value  in  laryngeal  coughs,  in  chronic  catarrhal  conditions  of  the  lungs 
or  intestine,  in  chronic  nephritis,  and  in  chronic  phthisis. 

KUMISS  CURE 

This  is  a  mode  of  cure  much  used  in  Russia.  Patients  who  are  to 
take  the  cure  are  generally  sent  to  the  country,  where  kumiss  can  be 
had.  It  is  given  frequently  during  the  day — as  often  as  every  half- 
hour — but  not  for  two  hours  before  a  heav.y  meal,  the  doses  being 
gradually  increased.  The  diet  used  with  it  consists  chiefly  of  meat 
and  fat.  Sugar,  fruits,  salads,  ices,  coffee,  and  alcohol  are  abstained 
from.  If  it  causes  diarrhea,  lime-water  is  added.  During  cold 
weather  it  produces  an  increase  in  the  excretion  of  urine,  and  during 
warm,  it  increases  the  perspiration.  Constipation  is  overcome  and 
there  is  a  gain  in  weight.  Sligl\t  drowsiness,  as  in  the  milk  cure,  may 
occur,  and  stimulation  of  the  sexual  organs  may  take  place. 

This  cure  is  useful  in  pulmonary  tuberculosis  and  when  there  is  a 
decided  lowering  of  the  nutrition.  The  effects  are  those  obtained 
from  a  generous  diet  combined  with  open-air  life. 

BUTTERMILK  CURE 

Of  recent  years  buttermilk  and  allied  preparations  have  been  used 
very  extensively  by  the  laity  in  the  treatment  of  a  great  many  ditferent 
conditions.  Buttermilk  has  certain  uses  in  a  diet,  and  the  following 
conditions  in  which  it  is  of  particular  value  should  be  borne  in  mind : 
(a)  "Where  fat  is  not  digested,  especially  in  acute  or  chronic  fat 
diarrhea;  (&)  in  infants  and  children  where  there  is  marasmus  or 
malnutrition,  due  to  fat  diarrhea  or  indigestion;  (c)  in  certain  forms 
of  chronic  dyspepsia,  especially  those  in  which  there  is  constipation ; 
(d)  in  fermentative  diarrheas;  (e)  in  typhoid  fever,  where  ordinary 
milk  is  not  well  borne;  (/)  following  surgical  operations,  where  the 
patient  does  not  bear  plain  milk  well. 

The  curative  effects  of  buttermilk  depend  chiefly  on  two  things : 
First,  the  low  fat  content,  making  it  of  great  value  where  fat  is  not 
well  borne ;  and,  secondly,  the  presence  of  the  lactic  acid  bacilli.  In 
fermentative  conditions  lactic  acid  bacilli  seem  to  be  able  to  drive  out 
the  offending  bacteria,  and  so  reestablish  a  more  or  less  normal  bac- 
terial flora  in  the  intestinal  tract.  Whole  milk,  which  has  been  inocu- 
lated Avith  lactic  acid  bacilli,  is  frequently  substituted  for  buttermilk, 


686  DIET  IN  DISEASE 

but  it  should  be  borne  in  mind  that  these  preparations  should  not  be 
used  where  the  disease  is  due  to  fat  indigestion. 

Metchnikoff  has  extolled  the  virtues  of  the  Bulgarian  buttermilk, 
and  preparations  of  the  Bulgarian  lactic  acid  bacilli  are  frequently 
used  in  this  country. 

THE  YOLK  CURE 

Yolk  of  egg  has  been  recommended  in  diabetes  (see  same),  and 
also  as  a  most  desirable  food  for  the  underfed  and  individuals  suffer- 
ing from  malnutrition.  In  many  cases  where  the  whole  egg  is  not 
well  borne  the  yolks  may  be  used  to  great  advantage.  From  10  to  40 
yolks  may  be  taken  daily  in  addition  to  some  other  food.  The  fat, 
lecithin,  and  ferments  found  in  the  yolk  render  it  particularly  suited 
to  individuals  whose  nutrition  is  below  par  and  who  do  not  do  well  on 
ordinary  diet. 

Stern  ^  gives  the  following  sample  diet,  outlined  for  a  consumptive 
weighing  50  kilos  (110  lbs.),  whose  normal  weight  should  be  63.6 
kilos  (140  lbs.): 

Number  Calories  Total 

of  in  the  number  of 

yolks.  yolks.  calories. 

Breakfast  : 

250  c.c.  skim  milk  with  4  yolks 4  200  200 

30  grams  wheat  toast   '.  .  .  .  75 

Early  L imch  : 

Cup  of  coffee,  2  yolks   2  100  100 

Dinner: 

One  plate  of  soup,  4  yolks   4  200  225 

Beef    ( very  lean)    150  grams    125 

30  grams  wheat  toast   75 

-)  o'clock: 

25  c.c.  skim  milk,  30  o.c.  whisky,  3  yolks 3  150  370 

Supper : 
Porridge   of   farina   or   rice    100  grams,    1   yolk, 

skim   milk    1  50  350 

Apple  sauce,  75  grams 30 

At  bedtime: 
Night   cap    (90    c.c.    hot    water,    10    c.c.    whisky, 

1  yolk,  teaspoonful  granulated  sugar)    ....        1  50  110 

15  750  1750 

The  diet  should  be  made  as  varied  as  possible  if  the  treatment  is  to 
extend  over  any  great  length  of  time,  and  dishes'  devised  in  which 
the  yolks  may  be  incorporated. 

OTHER  DIET  CURES 

Numerous  methods  of  curing  various  diseases  by  means  of  special 
diets  have  been  advocated  by  physicians  and  laymen  from  time  to 
time.  For  the  most  part  they  have  been  the  outcome  of  ignorance 
or  of  fanaticism,  and  they  have  often  been  associated  with   some 

1  Medical  Record,  Dec.  31,  1904. 


SPECIAL  DIETS  687 

religious  exercise.  Their  popularity  has,  as  a  rule,  been  ephemeral. 
They  are  suited  to  those  who  habitually  overeat.  Among  the  better 
known  are  the  follow^ing: 

The  Grape  Cure. — This  is  carried  out  chiefly  in  grape-growing 
countries  during  the  vintage  season.  It  is  recommended  for  chronic 
constipation,  for  those  individuals  who  have  enlarged  congested  livers, 
for  obesity,  and  for  various  lithemie  conditions;  its  use  has  also  been 
suggested  for  manj-  other  conditions  of  the  lungs,  stomach,  etc. 

The  cure  consists  in  visiting  the  grape  district  and  in  eating  from 
four  to  six  pounds  of  grapes  daily.  Even  larger  quantities  are  some- 
times taken.  It  is  recommended  that  the  fruit  be  taken,  when  pos- 
sible, on  rising  and  between  meals.  When  this  disagrees,  as  it  often 
does,  the  grapes  are  taken  at  the  close  of  a  meal.  The  patient  is  given 
at  the  same  time  an  easily  digested  but  nutritious  diet.  The  grapes 
have  a  decidedly  laxative  effect,  which,  combined  with  the  change  of 
scene  and  pleasant  outing,  often  produces  most  beneficial  results. 
Wlien  taken  in  too  large  quantities  or  in  poorly  selected  cases,  unpleas- 
ant symptoms,  such  as  swelling  of  the  gums  from  the  acid  and 
diarrhea,  may  occur. 

Other  Fruit  Cures. — Other  fruits  are  often  used  in  various  cures 
lasting  from  a  month  to  six  weeks.  Apples,  pears,  oranges,  lemons, 
in  fact,  almost  all  fruits  have  been  vaunted  at  some  time  as  cures. 
Various  methods  are  followed,  the  basis  of  all  being  a  greatly  re- 
stricted diet  with  an  abundance  of  finiit. 

They  are  used  in  the  same  diseased  conditions  for  which  the  grape 
cure  has  been  prescribed. 

Dry  Cure. — This  consists  in  taking  as  little  water  as  is  consistent 
with  life.  The  water  taken  in  addition  to  that  contained  in  the  food 
has  been  restricted  in  some  cases  to  a  pint  a  day.  This  treatment  has 
been  recommended  for  effusions  in  the  serous  cavities  and  joints,  in 
obesity,  and  in  gastric  dilatation.  Many  unpleasant  and  dangerous 
symptoms  may  follow  this  treatment.  Tufnell's  treatment  for  eneu- 
rysm  is  founded  on  the  same  principle. 

Schroth's  Cure. — This  is  a  form  of  the  dry  cure  used  in  Europe 
for  dilatation  of  the  stomach,  chronic  peritonitis,  and  various  other 
conditions.  The  amount  of  food  is  reduced  for  several  days,  and  then 
nothing  is  given  but  dried  bread,  with  the  addition,  at  dinner,  of 
boiled  vegetables.  A  small  quantity  of  hot  wine  is  allowed  to  quench 
the  thirst.  When  the  thirst  becomes  intolerable,  the  patient  is  given 
large  quantities  of  hot  wine  and  then  the  quantity  is  again  reduced. 
This  treatment  is  severe,  and  great  suffering  is  engendered,  dangerous 
and  even  fatal  complications  often  ensuing.  It  has  been  said  to  be 
beneficial  in  some  cases. 

The  Meat  and  the  Hot=water  Cure. — These  resemble  somewhat 
the  Carlsbad  and  similar  dietetic  methods  used  in  obesity  and  in 
dilatation  of  the  stomach.     The  diet  consists  chieflv  of  meat-fiber. 


688  DIET  IN  DISEASE 

eggs,  and  dry  toast.  Hot  water  is  taken  before  meals  and  at  bed- 
time. 

The  Kneipp  Cure. — This  consists  chiefly  of  a  diet  of  fruit,  bread, 
and  milk,  with  small  quantities  of  meat  and  vegetables.  The  cure 
directs  that  the  patient  walk  barefooted  in  the  grass  while  the  dew  is 
still  on  it.  It  became  popular  a  few  years  ago  among  the  faddists 
and  among  those  who  habitually  overfed. 

Fletcherism. — Countless  fads  in  feeding  have  been  brought  for- 
ward and  for  the  most  part  have  been  short-lived.  The  method 
of  Fletcher,  however,  has  stood  the  test  of  a  number  of  years  and  is 
now  included  in  the  Instructions  to  the  Medical  Department  of  the 
United  States  Army  under  the  heading  "iMethod  of  Attaining 
Economic  Assimilation  of  Nutriment  and  Immunity  from  Disease, 
Muscular  Soreness  and  Fatigue." 

Fletcher's  chief  points  are  "Wait  for  a  true,  earnest  appetite. 
Select  from  the  food  available  that  which  appeals  most  to  the  appetite 
and.  in  the  order  called  for  by  the  appetite.  Get  all  the  good  taste 
that  is  in  food  out  of  it  in  the  mouth  and  swallow  only  when  it  prac- 
tically swallows  itself.  Enjoy  the  good  taste  for  all  it  is  worth  and 
do  not  allow  any  depressing  or  diverting  thought  to  intrude  upon  the 
ceremony.  Wait;  take  and  enjoy  as  much  as  possible  what  appetite 
approves;  nature  will  do  the  rest." 

If  there  is  no  appetite  wait  for  the  next  meal  and  dispel  hunger  if  it 
comes  by  taking  water. 

The  result  of  the  thorough  comminution  and  insalivation  of  tlie  food 
leads  to  a  thorough  digestion  and  assimilation  and  the  resulting  feces 
are  odorless  or  nearly  so  and  remain  so.  This  method  is  useful  espe- 
cially when  there  is  decomposition  in  the  intestines  with  the  resulting 
joint  or  muscle  pain  and  lassitude  and  a  disposition  to  tire  easily. 
To  acquire  the  habit  requires  strict  attention,  particularly  in  the 
beginning,  but  once  the  habit  is  formed  seems  to  offer  little  difficulty. 
Fletcher  also  believes  iii  a  low  protein  diet  and  in  low  total  caloric 
value  for  those  of  sedentary  habit.  The  meals  need  not  take  over  half 
an  hour  and  if  strict  attention  is  paid  to  the  mastication  tifteen 
minutes  may  suffice  to  satisfy  the  appetite. 

SALT-FREE  DIET 

This  has  been  mentioned  in  connection  with  several  diseases,  and  a 
few  words  concerning  it  will  be  found  useful.  The  sodium-chlorid 
content  of  the  body  is  of  great  importance,  and  what  might  be  called 
sodium-chlorid  equilibrium  is  maintained  in  normal  individuals.  If 
the  amount  taken  in  food  is  increased,  there  is  an  increase  in  the  elim- 
ination, and  if  the  amount  be  reduced,  there  is  a  diminution  in  the 
output ;  but  a  certain  amount,  about  2  grams,  must  be  taken  daily  to 
make  up  for  the  inevitable  daily  loss.  The  ordinary  intake  of  sodium 
chlorid  is  about  15  to  20  grams  a  day,  and  if  this  is  omitted  from  the 


SALT-FREE  DIET  689 

diet,  there  is  a  corresponding  loss  of  fluid  from  the  body  of  about 
1  to  2  kilograms. 

Carnivorous  animals  and  people  do  not  use  salt  and  may  object  to 
it,  while  herbivorous  animals  and  vegetarians  require  it;  and  the 
average  omnivorous  man  also  craves  it,  and  the  average  individual 
takes  much  more  than  needed  simply  because  the  taste  for  salt  is 
cultivated  by  many.  The  large  amount  of  potassium  in  the  vegetables 
drives  out  the  sodium  of  the  sodium  chlorid  in  the  tissue.  Rice,  which 
contains  but  little  potassium,  is  the  exception,  and  rice-eating  peoples 
do  not  have  the  salt  craving  as  markedly  as  other  vegetable-eating 
peoples.  In  some  diseases,  as  in  nephritis,  there  is  a  disturbance  of 
salt  metabolism,  and,  as  a  rule,  there  is  salt  retention.  If  there  is 
unilateral  kidney  disease,  there  may  be  differences  in  the  salt  output 
of  the  two  kidneys.  In  normal  individuals  the  addition  of  an  extra 
amount  of  sodium  chlorid  causes  an  increase  in  the  excretion,  but 
where  there  is  salt  retention  it  does  not.  Salt  retention  is  generally 
accompanied  by  edema.  First  there  is  an  increase  in  weight  before 
the  edema  is  apparent.  It  is  usually  assumed  that  the  salt  retention 
causes  the  retention  of  the  water.  The  retention  of  the  water,  how- 
ever, would  cause  a  retention  of  the  sodium  chlorid  in  order  to  bring 
up  the  fluid  to  the  proper  composition.  All  edemas  are  not  due  to 
salt  retention,  a  fact  that  must  constantly  be  borne  in  mind  in  using 
salt-free  diets. 

When  edema  is  due  to  salt  retention,  the  restriction  of  the  intake 
of  salt  will  aid  greatly  in  the  elimination  of  the  fluid.  Restriction  of 
salt  generally  causes  an  increase  in  the  elimination  of  it,  due,  doubt- 
less, to  the  increased  permeability  of  the  kidneys  due  to  the  rest. 
This  excessive  secretion  keeps  up  until  conditions  in  the  body  have 
become  normal.  If  carried  to  excess,  salt  restriction  may  cause  edema. 
Salt  restriction  also  favors  sweating  and  elimination  of  water  through 
the  lungs. 

Salt  restriction  must  be  practised  consistently  over  considerable 
periods  of  time,  and  it  may  be  one  or  two  weeks  before  the  effect 
begins  to  be  noticed,  and  even  six  or  seven  weeks  may  elapse  before 
improvement  takes  place.  Generally  the  effect  is  prompt ;  occa- 
sionally there  may  be  a  temporary  increase  in  the  edema,  followed  by 
great  benefit.  The  diet  may  be  kept  as  near  the  minimum  require- 
ment of  2  grams  a  day  as  long  as  necessary.  The  increase  should  be 
made  slowly  and  the  effect  noted. 

Salt  restriction  may  be  tried  in  the  edema  of  nephritis,  and  in  that 
from  heart  disease  and  from  other  causes.  It  may  be  tried  in  diabetes 
insipidus,  in  which  disease  it  is  said  to  be  of  occasional  service ;  in  all 
conditions  in  which  it  is  desirable  to  limit  the  intake  of  water,  as  in 
obesity,  heart  disease,  and  when  there  are  serous  exudates.  In  ex- 
tremely nervous  and  irritable  people  it  may  be  tried,  and  it  has  been 
suggested  in  epilepsy.  It  increases  the  potency  of  the  bromids.  It 
44 


690  DIET  IN  DISEASE 

has  been  suggested  in  scarlet  fever  as  a  protection  against  nephritis. 
It  has  also  been  advised  in  tinnitus  aurium,  especially  that  occurring: 
in  Bright 's  disease,  and  also  in  the  chronic  obstructive  nasal  catarrli 
which  is  sometimes  seen  as  an  accompaniment  of  the  same  disease. 
Various  skin  diseases,  as  certain  forms  of  pemphigus,  have  also  been 
treated  in  this  way,  and  a  trial  may  be  made  in  certain  persistent 
eczemas. 

Richartz  has  suggested  the  use  of  salt  restriction  in  the  treatment 
of  gastric  hypersecretion.  He  also  suggests  the  use  of  systematic 
lavage  in  these  cases.  The  treatment  should  extend  over  a  long  period 
of  time  to  secure  the  best  results. 

The  tables  in  the  article  on  Salts  and  on  Gastric  Hyperacidity  will 
be  found  of  interest  in  connection  with  the  practical  application  of 
this  form  of  therapy. 

A  salt-free  diet  may  be  easily  arranged  with  the  cooperation  of  the 
cook,  and  may  consist  of  the  following  articles  of  diet,  from  which  the 
patient  can  very  easily  subsist.  These  can  be  modified  according  to 
the  disease  for  which  the  patients  are  being  dieted : 

Bread  should  be  made  without  salt.  The  average  bread  contains 
about  10  grams  for  each  kilogram,  sometimes  more.  The  bread  which 
has  not  had  salt  added  to  it  contains  about  0.7  eg.  per  kilo. 

Meat  should  always  be  used  fresh,  and  most  people  experience  little 
difficulty  in  eating  it  without  salt.  The  cook  should  be  instructed  not 
to  use  salt  in  its  preparation.  Meat  contains  on  an  average  about  1 
gram  per  kilo. 

Fresh-water  fish  may  be  used,  but  salt-water  varieties  contain  large 
amounts  of  sodium  chlorid. 

Fresh  eggs  may  be  taken  in  any  form  desired,  each  egg  eantaining- 
about  25  eg. 

Fresh  butter  that  is  unsalted,  fresh  cream,  and  saltless  cheese  may 
be  used  freely. 

Potatoes  may  be  prepared  in  many  varieties  of  ways,  and  may  be 
made  palatable  without  the  addition  of  salt.     The  same  is  true  of  rice. 

In  addition  to  the  above,  green  peas,  carrots,  leeks,  endive,  lettuce, 
French  beans,  celery,  artichokes,  and  salads  of  various  kinds  may  be 
added  to  the  dietary. 

Sweetmeats,  pastry  made  without  salt,  and  raw  or  cooked  fruit 
may  also  be  used. 

Chocolate  will  be  found  of  especial  value. 

Tea,  coffee,  and  beer,  or  even  wine  may  be  taken  as  far  as  the 
amount  of  chlorids  which  they  contain  are  concerned. 


SALT-FREE  DIET 


691 


SALT  CONTENT  OF  FOODS— FROM  LEVA 

NaCl  in  per  cent. 
of  natural  sub- 
stance. 

A.     Animal  Foods 

Meats. 

Calves'  kidney   0.32 

Calves'  brain    • 0.29 

Mutton    0.17 

Calves'  liver 0.14 

Veal      0.13 

Beef,  lean    0.11 

Pork,   lean .  0.10 

Lamb 0.09 

Frogs'  legs 0.05 

Rabbit 0.085 

Fish. 

Haddock    0.39 

Turbot,  fluke    0.33 

Halilnit    0.30 

Herring     0.27 

Mackerel    0.21 

Sole    0.21 

Codfish     0.16 

Salmon  trout    012 

Penh      0.10 

Pike     0.092 

Carp     0.086 

Pickerel     0.077 

Tench     0.073 

Salmon     0.061 

Eels    0.021 

Fovl. 

Goose     0.20 

Turkev     0.17 

Squal)'     0.15 

Chicken      0.14 

Duck    0.14 

Wild  (lame. 

Hare     0.16 

Roc     0.11 

Deer      0.10 

Oysters    (without  sea  water)    0.52 

Oysters    (with  sea  water)     0.14 

Dried   meat    6.3-14.1 

Smoked,  unsalted  meat. 

Smoked   bacon    (American)    11.61 

Cassel   (roast)   spare  ribs 8.7 

Smoked  salmon    7.5 

Raw  ham    4.15-5.86 

Prague  cooked  ham    3.48 

Cooked  ham    1.85-5.35 

Smoked  bacon    1-01 

Canned  meats. 

Corned  beef    (  American )     1 1  52 

Corned  beef   (  Australian )    0.25-4.42 

Corned  beef    ( German )     2.04 

Dried  fish. 

Codfish,  salted   3.56 

Codfish,   unsalted    0.19 

Smoked  Unsalted  Fish. 

Red    herring    0.38 

Kieler    sprat    0.31 


Protein  per  cent. 
.\verage.  For 
nitrogen  content 
divide  by   6.26. 


17.0 


17.0 
19.0 
20.0 
24.0 
17.0 
21.7 
15.5 


17.2 
14.8 
22.0 
19.5 

21.8 

21.0 
17.8 
18.0 
17.9 

18.7 

20.0 
18.6 

16.3 
21.1 
18.5 
19.3 
21.4 


30.0 

.15 
6.0 

2.5 

20.2 
10.5 

15.6 


25.4 
16.5 

36.9 


692 


DIET  IN  DISEASE 


NaCl  in  per  cent. 
of  natural  sub- 
stance. 

Sardines  (canned  in  mustard  or  oil)    0.12 

Smoked  Salt  Fish. 

Sardellan     20.59 

Pickled  herring 14.47 

Salmon    10.87 

Haddock    2.06 

Salt    (Marienierte)    Fish. 

Lamprey    (fluid  alone)    2.65 

Lamprej'    ( witlioiit  fluid )    1.79 

Fish  Conserved  in  Oil. 

Tunny  fish    5.49 

French   sardines    1.34 

Codliver  oil    0.17 

Dried    gelatin     0.75 

Beef  marrow    0.11 

Sausage. 

Gotha  Cervelat  wurst   6.16 

German  salami    5.37 

Italian  salami   4.S-S.1 

Hungarian   salami    4.6-5.4 

Munich  small  sausages   3.31 

Mett  wurst 3.15 

Liver   sausage    2,!1 

Frankfurters    2.2 

Regensburger  sausage    2.2-3.2 

German  sausage    2.77 

Pastes. 

Anchovy    paste    40.10 

Tongue  paste   5.98 

Ham  paste   5.72 

Salmon   paste    .-,.  5.65 

Lobster  paste 2.38 

Strasburg  goose   liver    2.22 

Soup  Material. 

Peas  and  sausage   (German  army)    11.7 

Peas  and  sausage   10.6 

Tapioca,  julienne,  potatoes,  peas,  etc 10.01-15.48 

Rumford  soup    10.0 

Split  peas,  lentils,  etc 8.18 

Beef  zwieback  soup   (Austrian  army)    0.6-4.77 

Meat  Extracts. 

Cibil's  fluid    14.62 

Liebig's      2.60 

Kemmereich's     1.40 

Sovp  Spices   {also  prepared  foods). 

Maggis  bouillon  cubes   53.13 

Maggis  soup  spices 18.30 

Maggis  bouillon  extract 9.37-22.46 

Other  Preparations. 
Kietz'  jelly  broth,  Herz'  Nervin,  Gusto  Bouil- 
lon Extract,  Bovos,  Vir,  Sitogen,  Ovos,  von 

Ibberts'  soup  extract   9.48-19.64 

Prepared  Sauces. 

Essence  of  shrimps,  anchovies,  etc 19.01-21.7 

Maggis  Concentre  de  truffes  aux  fines  lierbes, 

etc 12.53-20.8 

Nourishing  Preparations. 

Toril    16.73 


Protein  per  cent. 
Average.  For 
nitrogen  content 
divide   by   6.25. 

23.0 


22.3 
16.9 

21.7 
91.4 

24.1 
19.6 


SALT-FREE  DIET 


693 


NaCl  in  per  cent. 
of  natural  sub- 
stance. 

Toril    16.03 

Finzelberg  Nf.  dried  pepton    15.13 

Kemmereicbs'  Meat  Pepton    (fluid)    12.66 

Koch's  Meat  Pepton   ( fluid)    12.57 

Maggis  bouillon  extract   8.96-9.77 

Cibil's    preparation     8.80-14.68 

Bios      8.57 

Antweiler's  Pepton   5.85-13.41 

Fersan   (J.  JoUes-Wien)    3.83 

Maggis   Pepton    3.33-6.55 

Cibil's  Papava  Meat  Pepton   2.88 

Puro     '. 2.63 

Roborin      1.7 

Leube-Rosentbal's  Beef  Tea    1.2 

Kenimereich"s  ^Sleat  Pepton    (solid)    1.10 

Koch's  Meat  Pepton    (solid)    0.80 

Somatose     0.66 

Sanatogen     0.42 

Bovril's   Preparation    , 0.26-14.12 

Plasmon    0.21 

Benger's  Peptonized  Meat  Jelly    (fluid)    ....  0.16 

Hamatin-Albumin    (Finsen)      0.1.3 

Valentine's  Meat  Juice   0.08 

Roborat      0.0051 

Eggs. 

Caviar    (  German )    6.18 

Caviar    ( Russian  malossol)    3.0 

Hens'  eggs    (white)    0  31 

Hen's  eggs   fin  the  shell)    0.21 

Sea  gull   eggs    0.14 

Goose  eggs    0.14 

Duck   eggs    0.13 

Hen's  eggs    ( yolk )     0.039 

Milk  and  Dairy  Products. 

Margarine     2.15 

Arbora 1.01 

Butter   (salted)    1.0-3.0 

Condensed  milk   0.40 

Buttermilk    0.16 

Cow's  milk   (  full  milk )    0.16 

Cow's  milk    (skimmed  milk)    0.15 

Boumasohe    ( Diabetes  milk)    0.14 

Cream  cheese   0.13 

Whey     0.1 1-0.15 

Fructin    0.10 

Butter    (unsalted)     0.02-0.21 

Palmin     0.0016 

Cheese. 

Brick    cheese    10.57 

Mainzer  hand  cheese    4.36 

Romadour   cheese    3.91 

Gervais  cheese    (salted)     3.43 

Edam     3.30 

Brie   cheese    3.15 

Swiss    cheese    2.0 

Parmesan  cheese     ' 1.93 

Chester      1.59-1.91 

Stracchino     1.0-1.3 

English   cream   cheese    0.7-1.15 

Cheddar     0.23-1.97 


Protein  per  cent. 
Average.  For 
nitrogen  content 
divide  by  6.25. 


12.3 
13.4 


15.7 

1.2 

1.0 

8.8 

3.0 

3.50 

3.4 

25.0 
1.0 

1.0 


27.6 
37.1 
15.9 
30.85 


30.1 

27.7 


694 


DIET  IN  DISEASE 


NaCl  in  per  cent, 

of  natural    sub- 
stance. 

German  cream  cheese 0.20 

Potted  cheese     0.18 

Gervais  cheese    ( unsalted)    0.13 

Infant's  Food. 

Voldmer's   Mother's   Milk    0.70 

Loflund's  Peptonized  i\lilk    0.65 

Epprecht's  Food    0.39 

Nestles'    Food    0.29 

Loflund's  Peptonized  Milk    0.22 

Liebes'  Food  in  soluble  form   0.14 

Rademann's   Infant   Food    0.0.3 

Kufeke's  Children's  Food    0  09.5 

Loflund's   Children's   Food    0,074 

Muffler's  sterilized  Children's  Food   0  041 

Robinson's   Patent   Groats    Trace 


Protein  per  cent. 
Average.  For 
nitrogen  content 
divide  by  6.25. 

5.2 
27.6 


B.  Vegetables  and  Breadstuffs. 


Bread,  Etc. 

Barley  bread    

Army  hard  tack    

Petit   beurre    (Bielefeld) 

Gray  bread   (oats  and  rye)    

Wheat  bread    

Wheat  bread    (Berlin  rolls)    

Berlin  black  bread    ... 

Graham  bread   

Oat  bread    

Leibnitz-Kakes     

Pumpernickel    (brown  bread)    

Gray  bread   ( rye  and  maize )    

Waffles 

Zwieback     

Aleuronat  bread    

Brown  bread   ( ammunition  bread )    . .  . 
Gray  bread   (§  rye  and  J  white  meal) 

Wheat  bread    

Gray  bread   (white  and  rye)    

Macaroni     

Noodles    ( thin )     

Cereals  and  Meal  Products. 

Rolled    oats    

Hominy  grits    ( American )    

Hominy  grits   (German)    

Hominy    grits    

Sago     

Buckwheat      

Quaker    oats    

Oats      

Rice    

Barley    

Millet     

Maize     

Ricemeal    

Rye     

Oatmeal     

Wheat      

Cornmeal     

Tubers. 
Potatoes    


1  .38 

0.95-160 

11.1 

0.87 

7.9 

0.71 

0.70 

8.0 

0.69 

9.4 

0.66 

0.61 

0.48 

0.47 

0.46   ' 

0.40-0.68 

0.40 

0.38 

9.8 

0.34 

0.21-068 

0.18-0.59 

11.9 

0.18 

8.0 

0.15-0.48 

11.9 

0.067 

13.4 

0.064 

11.7 

0.35 

16.7 

0.29 

8.3 

0.28 

0.26 

8.3 

0.19 

0.06 

6.4 

0.082 

16.7 

0.046 

16.1 

0.039 

8.6 

0.037 

10.5     . 

0.024 

6.6 

0.019 

7.0 

0.016 

8.6 

0.014 

6.8 

0.014 

16.0 

0.013 

8.0-13.0 

0.002-0.008 

9.2 

0.16-0.078 

2.2 

SALT-FREE  DIET 


695 


NaCl  in  per  cent. 
of  natural  sub- 
stance. 

Sweet  potatoes    O.IG 

Carrots    0.06 

Kohlrabi     0.072 

Rutabaga    0.058 

Legumins. 

Lentils     0.13-0.19 

Beans     0.09 

Lentils   (dried)    0.155 

Peas     0.058 

Vegetables  ( fresh ) . 

Spinach      0.84 

Celery    (stalks)     0.25-0.49 

Spinach 0.17-0.21 

Savoy  cabbage 0.16-0.44 

Lettuce    0.12 

White  cabbage  0.1 1-0.44 

Tomatoes 0.1 1 

Salads  (of  all  kinds)    0.08-0.17 

Black  radishes O.OS-0.15 

Cucumbers    0.06-0.08 

Cauliflower     0.0.1-0.15 

Pumpkin     0.05 

Asparagus     0.04-0.06 

Winter  cabbage   0.03-0.75 

Kohlrabi      0.0.3-0.21 

Horseradish    0.02-0.06 

Tomatoes 0.094 

Beans    (young)    0.089 

Celery  root 0.083 

Radishes    0.075 

Rhubarb    0.059 

Peas    ( fresh)    0.058 

Leek     0.040 

Artichokes    0.036 

Carrots    0.016-0.3 

Onions   0.016-0.09 

Canned  and  Airtight  Vegetables. 

Artichokes    1.27 

French  beans 0.83 

Asparagus     ".  .  .  .  0.83 

String   beans    0.77 

Soup  stock   0.76 

Peas    ( young)    0.67 

Tomatoes    0.14 

Pickled  Vegetables. 

Sour  gherkins   1-45 

Sauerkraut   0.73 

Mushrooms. 

Champignon     0.04-0.06 

Yellow   boletus    0.031 

Mqrelle    0.031 

Fruit. 

Raisins    ( Sultana)    0.16 

Almonds    (dried)     0.10 

Strawberries     0.01-0.02 

Currants     0.093 

Pineapple    0.071 

Cocoanut    ( milk )     0.035 

Grapes     0.024 

Gooseberries     0  02 1 


Protein  per  cent. 
Average.  For 
nitrogen  content 
divide  by  6.35. 

1.8 
1 
2 
1.3 


9.0 

25.7 

7.0 


2.1 
1.1 
2.1 
4.1 
1.2 
1.6 
0.9 
1-2 

0.8 
1.8 
1.0 
1.8 

2.0 
1.4 
0.9 


1.3 
0.6 

1.2 
2.6 
1.1 
1.4 

0.8 
1.1 
1.5 
1.2 

3.6 
1.2 

0.5 
1.7 

3.5 


2.6 

21.0 

0.7 

1.5 

0.4 
0.4 

2.8 


696  DIET  IN  DISEASE 

Protein    per    cent. 
NaCl  in  per  cent.  Average.         For 

of    natural    sub-  nitrogen  content 

stance.  divide   by   6.25. 

Figs      0.021                                4.3 

Walnuts    (dried)     0.019                              18.4 

Cherries     0.013                                1.1 

Watermelon    0.01 1                                0.4 

Olives     0.008-0.21                             1.7 

Oranges     0.0057                              0.4 

Apricots    0.0047                             4.7 

Damsons      0.0046 

Chestnuts    0.004.5-0.010                          6.2 

Plums     0.0045                               1.0 

Citron    0.0045                             0.5 

Sweets. 

Brown  sugar    0.28 

Raw  sugar    0.1 1 

Chocolate    0.073 

Lump  sugar    0.04fl 

Beet  sugar    0.0090 

Spices. 

Mustard     2.66 

Coriander  ( mixed  with  salt)    2.1 

Pepper    ( black )     0.51                         , 

Fennel      0.43 

Dill     0.41 

Marjoram      0.31 

Paprika     0.27 

Bay  leaves    0.27 

Coriander    (mixed  with  vinegar)    0.20 

Saffron     0.12 

Cinnamon      0.061 

Vanilla    0.055 

Poppy    seeds    0.038 

Pepper     (white)     0.019 

Alkaloid  Containing  Articles. 

All  kinds  coffee   (roasted)    0.01-0.33 

Tea     0.15 

Cocoa  beans 0.05-0.095 

Coffee    ( roasted )    0.045 

C.    Beverages. 

Beer    ( English )     0.10 

Eggnogg    0.045 

Beer    ( German )     0.016 

Light  beer    0.015 

Champagne    (Moet  and  Chandon)    0.0045 

Pomril     0.0027 

City  main  water    0.0031-0.0035 

Ale     0.0017 

Underground  water    0.0012-0.006 

Spring  water   0.00055-0.0046 

Table  Waters. 

Seltzer   water    (plain)     0.23 

Namedy  sparkling    0.19 

Seltzer  water    (sparkling)    0.10 

Sparkling  Rhenser    0.125 

Vichy     0.053 

Apollinaris      0.043 

Biliner     0.039 

Fachinger 0.039 

Salvator    0.017 


SALT-FREE  DIET 


697 


D.    Other  Articles  of  Food. 


ISoiips. 

Bouillon     

Barley  broth    

Bouillon     

Peas  and  rice  soup   (Maggi)    

Potato  soup    

Bouillon     

Rice  soup    

Tapioca- Julienne     ( Maggi )     

Cream   soup    

Bouillon     

Gruel    ( IMaggi )     

Milk  porridge  1 

Wine  soup        i-The  A  B  C  of  the  kitchen   .  . 

Apple  soup       j 

Meat  Dishes. 

Baked   tongue    

Boiled   pike    

Steamed   pigs'  kidney 

Roast  pork   

Chopped  beef  steak    

Baked  calves'  brain    

Roast  veal    

Filet  of  beef    

Roast  beef    

Mutton  cutlet    

Boiled   lobster    

Roast  hare   

Roast  chicken    

Sauces. 

Sardellan    sauce    

Gravy     

Anchovy  sauce     

Eggs. 

Scrambled  eggs    (with  salt) . 

Boiled    eggs    

Scrambled  eggs   (with  sugar)    

Omelet  with  vinegar  (without  salt)    

Vegetables. 

Spinach      

Morelle    

Cauliflower     

Carrots    

Salad. 
Green   salad    

Preserves. 

Apple  sauce   

Pear    preserves    

Puddings. 

Macaroni    ( Italian)    

Milk   pudding    

Macaroni   (in  milk  and  sugar)    

Rice  and  apples   

Chocolate   blancmange    

Tapioca  pudding   

Tapioca    pudding     (without    salt,    sugar    or 
spices)      


NaCl  in  per  cent. 
of  natural  sub- 
stance. 

1.0 

0.9 

0.59-0.8 

0.57 

o.-'se 

0.55 
0.54 
0.54 
0.53 
0.49 
0.34 
0.25 

0.2.3 

0.015 

1.92 
1.84 
1.61 
1.54 
1.29 
1.24 
l.ll 
1.04 
0.98 
0.97 
0.95 
0.76 
0.39 

1.5 
0.8 
0.75 

1.1 

0.98 
0.19 
0.18 

0.91 
0.68 
0.49 
0.46 

0.41 

0.031    . 
0.019 

1.04 

0.40 

0.29 

0.18 

0.061 

0.027 

0.026 


Protein    per    cent. 
Average.  For 

nitrogen  content 
divide   by   6.25. 


12.6 


Forced    Feeding. — Forced   or   excessive    feeding   is   utilized   with 


698  DIET  ly  DISEASE 

benefit  in  certain  diseased  conditions  with  certain  limitations:  (see 
Tuberculosis,  the  Rest  Cure,  and  Diseases  of  the  Stomach),  but  it  is 
well  to  note  that  in  most  conditions  forced  feeding  is  productive  of 
unsatisfactory  results,  and  the  efit'ect  on  normal  individuals  is  dis- 
tinctly bad.  The  effect  of  the  excessive  diet  is  a  rapid  increase  in 
weight  during  the  period  in  which  the  individual  is  so  fed,  and  general 
symptoms  of  discomfort,  such  as  heaviness,  indisposition  to  exercise, 
feeling  of  distention  and  weight  in  the  abdomen,  disturbed  sleep, 
sometimes  dj'spnea  on  exertion,  often  pain  in  the  region  of  the  liver 
and,  later,  diarrhea,-  often  of  a  severe  type.  There  is  marked  increase 
in  the  inorganic  constituents  of  the  urine,  the  urine  is  increased  in 
quantity,  and  there  is  a  marked  increase  in  the  quantity  of  total 
nitrogen  in  the  urine,  the  proportion  passed  as  urea  remaining 
normal. 

Fat=free  Diet. — A  fat-free  diet  is,  of  course,  impossible,  but  a  diet 
low  in  fat  may  easily  be  arranged  and  it  has  been  suggested  in  cer- 
tain diseases  of  the  stomach,  particularly  in  catarrhs,  either  with  or 
without  atony  and  dilatation.  It  has  also  been  suggested  in  cases  in 
which  the  free  hydrochloric  acid  is  absent  or  greatly  diminished,  in 
cancer  and  in  acidosis. 

Tibbies  gives  the  following  list  of  fat-free  foods:  sugar,  honey, 
syrup,  starch,  beef-tea,  meat  extracts,  casein  preparations,  and  the 
whites  of  eggs. 

Foods  containing  0.5  per  cent,  or  less :  Skim  milk,  casein  powders, 
sugar,  corn-starch,  arrowroot,  sago,  tapioca,  green  peas,  string  beans, 
potatoes,  parsnips,  carrots,  turnips,  radishes,  beetroot,  salsify,  cab- 
bage, cauliflower,  brussels-sprouts,  spinach,  vegetable  marrow,  squash, 
asparagus,  tomatoes,  mushrooms,  truffles,  onions,  leeks,  celery,  lettuce, 
watercress,  cucumber,  rhubarb ;  apples,  pears,  peaches,  plums,  straw- 
berries, raspberries,  gooseberries,  currants,  muskmelons,  melons, 
watermelons,  oranges ;  litchi  nuts ;  and  the  white  of  eggs. 

Foods  containing  less  than  1  per  cent,  of  fat :  In  addition  to  the 
foregoing — fine  white  flour,  white  bread,  rj^emeal  and  rye  bread, 
beef-tea,  meat  extracts,  beef  broth,  meat  stews  when  skimmed,  tomato 
soup,  oxtail  soup,  mulligatawny  soup,  pea  soup,  gumbo  soup.  Turtle, 
frog's  legs,  oysters,  clams,  scallops,  crab,  crayfish,  shrimps.  Fish: 
bass,  cod,  cusk,  flounder,  haddock,  hake,  yellow  perch,  perch-pike,  grey 
pike,  pickerel-pike,  pollock,  red  grouper,  and  red  snapper. 

Foods  with  1  to  2  per  cent,  of  fat:  Sole,  plaice,  smelt,  sturgeon, 
weak-fish,  skatp,  blue-fish,  black-fish,  king-fish.  Venison :  partridge, 
breast  of  boiled  fowl ;  wheat,  brown  bread,  wholemeal  bread,  buck- 
wheat flour,  macaroni,  vermicelli,  haricot  and  navy  beans,  dried  peas, 
frijoles,  green  corn ;  grapes  and  bananas. 


THE  DIETETIC  MANAGEMENT  OF  SURGICAL 

CASES 

Preparation  for  Operation. — Surgical  operations  that  must  be  per- 
formed immediately,  of  course,  admit  of  no  preparation.  Most  oper- 
ations, however,  may  be  postponed  for  several  days  or  longer,  thus 
enabling  the  patient  to  be  put  in  good  condition  by  rest,  preferably  in 
bed,  and  a  nourishing,  easily  digested  diet.  This  is  of  great  im- 
portance in  nervous  women,  and  no  major  operation  should  be  under- 
taken, except  when  urgently  demanded,  without  giving  the  patient  the 
benefit  of  the  "building-up  process.''  A  plan  that  seems  to  be  pop- 
ular at  the  present  day,  especially  among  gynecologists,  is  to  operate 
first  and  then  to  build  up  the  patient.  Were  this  plan  reversed,  many 
operations  could  be  avoided  altogether.  The  truth  of  this  is  illus- 
trated by  the  following  case:  A  nervous  young  woman  of  twenty 
was  advised  by  a  surgeon  to  undergo  operation  for  the  anchoring 
of  a  movable  kidney.  Later  she  consulted  an  eminent  physician,  who 
prescribed  rest  with  proper  nourishment  under  the  care  of  a  competent 
nurse.  In  six  weeks'  time  her  gain  in  weight  was  such  that  the  kid- 
ne}-  became  anchored  in  normal  fat,  whereas  all  nervous  symptoms 
had  disappeared. 

The  value  of  rest  in  bed  is  greatly  augmented  by  massage,  elec- 
tricity, and  baths ;  b}'  tonics ;  and  by  laxatives  to  correct  the  tendency 
to  constipation  that  usually  exists. 

Diet  and  Laparotomies. — One  or  two  days  previous  to  the  opera- 
tion the  bowels  should  be  cleansed  thoroughly  by  a  saline,  such  as 
sulphate  of  magnesia,  and  in  the  case  of  abdominal  or  pelvic  opera- 
tions, an  enema  or  two  may  be  given  in  addition,  the  object  being  not 
only  to  secure  cleanliness,  but  to  obtain  rest  for  the  bowels.  Licorice 
powder  may  be  substituted  as  a  laxative,  or  in  delicate  patients  aloes, 
cascara  sagrada,  or  citrate  of  magnesia  may  be  employed.  The  wash- 
ing-out of  the  rectum  should  be  performed  early  on  the  morning  of 
the  operation — at  six  or  seven  o'clock  or  at  least  three  hours  before 
the  operation. 

The  diet  on  the  day  previous  to  the  operation  should  be  light.  On 
the  morning  of  the  operation  a  glass  of  milk  or  a  cup  of  very  weak 
cocoa  or  beef-tea  should  be  given.  There  is  no  objection  to  adding  a 
small  piece  of  toast,  a  biscuit,  or  a  cracker.  This  should,  however, 
precede  the  operation  by  at  least  three  or  four  hours.  If  the  opera- 
tion is  performed  early  in  the  morning,  nothing  need  be  given  before 
it.  Operation  upon  the  gastro-intestinal  tract  should  be  preceded  by 
the  special  diet  given  below  (Diet  following  Operation  on  the 
Stomach). 

699 


700  THE  DIETETIC  MANAGEMENT  OF  SURGICAL  CASES 

After  the  operation  there  is  usually  nausea.  This  may  be  lessened 
or  entirely  prevented  by  a  method  which  has  been  practised  for  some 
time  in  Halsted's  service  at  the  Johns  Hopkins  Hospital  and  in  Fin- 
ney's at  the  Union  Protestant  Infirmary  of  Baltimore  in  cases  of 
ether  anesthesia ;  namely,  washing-out  of  the  stomach  after  all  surgi- 
cal procedures  while  the  patient  is  on  the  table  and  still  under  the 
influence  of  the  anesthetic.  C.  S.  White/  too,  extols  this  method  in 
a  report,  in  which  he  shows  that  in  a  series  of  20  consecutive  cases, 
60  per  cent,  did  not  vomit,  while  in  lUO  consecutive  cases  of  ether 
anesthesia  without  lavage  only  30  per  cent,  did  not  vomit. 

As  a  rule,  nothing  should  be  given  by  mouth  for  twenty-four  hours. 
Very  small  quantities  of  carbonated  water  or  iced  water  or  of  very 
hot  water  may  be  given,  or,  if  the  patient  is  weak  and  in  need  of 
nourishment,  milk  may  be  given  in  teaspoonful  doses,  lime-water  or 
a  carbonated  water  may  be  added  to  the  milk  if  necessar3\  Hot  weak 
tea  is  often  acceptable  to  the  patient,  and  if  there  is  need  of  a  stimu- 
lant, strong  black  coffee  may  be  administered ;  or  if  an  alcoholic 
stimulant  is  desired,  champagne  in  small  doses  or  good  brandy  diluted 
with  aerated  water  may  be  prescribed.  If  champagne  or  good  brandy 
cannot  be  obtained,  very  old  pure  whisky  may  be  used.  For  the  first 
twenty-four  or  forty-eight  hours  the  diet  should  be  liquid — milk  or 
one  of  the  liquids  given  in  the  diet-list  below.  Usually  from  5  to  10 
ounces  of  food  will  be  taken  the  second,  and  from  10  to  15  ounces  the 
third  day.  On  the  fourth  day,  if  there  are  no  untoward  symptoms 
and  it  is  deemed  advisable,  a  soft  diet  may  be  given.  (See  list 
below.)     After  a  week  or  ten  days  the  ordinary  diet  may  be  resumed. 

Nausea  and  Vomiting. — This  is  more  frequent  after  prolonged 
operations  and  when  ether  has  been  the  anesthetic  used,  but  can  often 
be  prevented  by  washing  out  the  stomach  while  the  patient  is  still 
under  the  influence  of  the  anesthetic,  as  has  been  mentioned.  Nausea 
and  vomiting  are  less  frequently  occasioned  by  the  drop  method  of 
producing  ether  anesthesia  than  by  the  method  of  administering  large 
quantities,  as  was  formerly  practised.  It  may  be  transitory  or  may 
continue  for  days  or  even  a  week,  depending  on  the  severity  of  the 
operation  and  also  on  personal  habit.  The  management  of  nausea 
and  vomiting  may  become  a  matter  of  the  greatest  difficulty. 

While  the  vomiting  is  active  no  food  should  be  given  by  the  mouth. 
If  it  persists  and  the  patient  is  weak,  rectal  enemata  may  be  pre- 
scribed unless  contraindicated  by  somei  special  operation.  These  may 
be  given  every  six  or  eight  hours,     (See  Rectal  Feeding.) 

Various  methods  for  the  relief  of  vomiting  may  be  tried.  A  tea- 
spoonful  or  two  of  hot  water,  to  which  has  been  added  a  drop  of 
dilute  of  hydrocyanic  acid  or  of  tincture  of  capsicum  to  an  ounce  or 
two  of  water,  may  be  effectual.  Teaspoonful  doses  of  iced  champagne 
may  be  useful,  as  may  also  the  following :     Drop  doses  of  creosote  in 

1  C.  S.  White,  Annals  of  Surgery,  August,  1904. 


CARE  OF  THE  BOWELS  701 

a  teaspoonful  or  two  of  lime-water;  drop  doses  of  spirits  of  chloro- 
form at  fre(iiieiit  intervals;  ten  or  twenty  minims  of  a  2  per  cent, 
solution  of  eoeain ;  morphin  in  very  small  doses,  or  bismuth  subnitrate. 
A  mustard  plaster,  an  ice-bag,  or  a  hot-water  bag  applied  to  the 
epigastrium  sometimes  brings  relief.  If  the  bowels  have  not  moved, 
the  vomiting  may  be  relieved  by  an  enema.  A  full  glass  of  hot  water 
frequently  gives  relief,  and  even  if  it  is  rejected  it  serves  to  wash  out 
the  stomach.  Washing  out  the  stomach  with  a  weak  boric-acid  solu- 
tion is  often  effective  in  checking  the  vomiting  when  all  other  methods 
fail.  Total  abstinence  from  food,  drink,  and  medicine  is  the  safest 
way  to  manage  the  majority  of  cases. 

Thirst. — This  is  often  a  troublesome  symptom;  in  some  cases  it  is 
almost  intolerable.  Kelly  has  reported  the  case  of  a  patient  who 
drank  about  a  quart  of  water  from  a  hot-water  bag  placed  at  her 
feet ;  many  similar  occurrences  could  be  cited.  Clark  reported  from 
Kelly's  wards  the  use  of  high  enemata  of  saline  solution  to  allay  the 
thirst  following  operation.  About  a  quart  of  solution  is  used.  The 
patient  must  he  fully  under  the  anesthetic  or  sufficiently  large  quan- 
tities will  not  be  retained.  "A  stiff  rectal  tube  is  inserted  well  up 
into  the  sigmoid  flexure,  and  the  fluid  is  slowly  poured  into  a  glass 
funnel  held  three  feet  above  the  patient's  buttocks."  "While  this  is 
being  done  the  patient's  buttocks  should  be  elevated  six  or  eight 
inches,  and  the  fluid  allowed  to  flow  well  into  the  colon.  It  is  very 
rarely  expelled.  Thirst  can  be  best  allayed  by  practicing  continuous 
enteroclysis  according  to  the  method  advised  by  ]\Iurphy.  If  this  can- 
not be  done  and  the  thirst  is  intolerable,  the  patient  may  be  given 
small  quantities  of  plain  hot  water,  carbonated  water,  or  hot  weak  tea. 
The  tea  is  often  retained  when  water  is  rejected. 

Care  of  the  Bowels. — As  a  rule,  by  the  third  day  after  operation, 
it  is  desirable  that  the  bowels  be  evacuated,  and  to  this  end  a  pill  of 
aloes,  belladonna,  and  strychnin  or  a  dose  of  cascara  or  licorice  powder 
may  be  given.  Calomel  is  a  favorite  drug  with  some  operators,  one- 
tenth  to  one-fourth  of  a  grain  being  given  every  half-hour  or  every 
hour  until  from  one  to  three  grains  have  been  given.  This  may  be 
followed  by  a  half-glass  of  citrate  of  magnesia,  a  few  drams  of  a  sat- 
urated solution  of  sulphate  of  magnesia,  or  a  dose  of  castor  oil.  If 
necessary,  an  enema  may  be  given.  Kelly  gives  the  following  for- 
mula of  Dr.  C.  P.  Noble : 

I^     Magnes.  siilph Jij  ; 

01.   terebinth ^ss; 

Glycerin 5J ! 

Aqua     qs.  ad.  ^iv. 

Sig. — Inject  into  the  bowel. 

Not  more  than  three  enemata  should  be  given  during  the  entire 
third  day. 

If  the  patient  is  doing  well  and  there  are  no  untoward  symptoms, 


702  THE  DIETETIC  MANAGEMENT  OF  SVRUWAL  CASES 

and  if  ordinary  efforts  do  not  produce  a  movement,  no  alarm  need 
be  felt  even  if  there  be  no  evacuation  up  to  the  sixth  day.  At  about 
this  time  they  will  often  move  naturally. 

Dietetic  Management  of  Shock. — Much  can  be'  done,  by  proper 
management  of  the  diet  before  the  operation,  to  prevent  shock. 
What  is  generally  spoken  of  as  the  building-up  process  should  be  re- 
sorted to,  especially  when  the  patient  is  very  much  debilitated,  before 
every  operation  that  will  permit  it. 

Following  the  operation,  in  addition  to  the  usual  means  of  stimula- 
tion, as  the  application  of  external  warmth  and  the  like,  stimulating 
and  nutrient  enemata  may  be  given.  The  first  enema  may  be  admin- 
istered while  the  patient  is  on  the  table  and  still  under  the  influence 
of  the  anesthetic.  This  may  be  repeated  every  three  hours,  or,  if  the 
patient's  condition  allows  it,  at  longer  intervals.  Kelly  recommends 
an  enema  consisting  of  two  ounces  of  brandy,  twenty  grains  of  car- 
bonate of  ammonia,  with  sufficient  water  or  beef -tea  at  37.8°  C.  (100° 
F.)  to  make  eight  ounces.  A  stimulating  enema  of  200  c.c.  salt  solu- 
tion and  200  c.c.  of  coffee  is  often  useful. 

Anesthesia  and  Diet. — The  relation  of  diet  to  anesthesia  is  one 
deserving  of  study;  as  yet  too  little  has  been  done.  Hawk  has 
shown  that  dogs  given  3  or  4  grams  of  carbohydrate  per  kilo  of  body- 
weight  failed  to  show  any  glycosuria  after  ether  anesthesia,  but  the 
same  dogs  for  ten  days  on  a  carbohydrate-free  diet  showed  glycosuria. 
The  question  of  post-anesthetic  glycosuria  would  seem  to  be  largely 
a  question  of  diet,  and  the  minimum  of  carbohydrate  per  kilogram  of 
body-weiglit  necessary  to  prevent  glycosuria  in  the  human  being- 
should  be  determined. 

Another  similar  question  is  that  of  postanesthetic  acidosis.  We 
have  seen  various  grades  of  acidosis,  particularly  following  ether. 
Children  who  have  been  starved  prior  to  operation  would  seem  to  be 
especially  liable.  As  the  condition  is  serious  and  at  times  even  fatal, 
we  would  suggest  the  administration  of  carbohydrate  food  the  day 
prior  to  the  operation  in  the  cases  where  this  is  feasible.  Where  it 
has  developed,  the  administration  of  glucose  solutions  by  rectum  by 
the  ^lurphy  drop  method  should  be  tried.  Thirty  grams  (1  ounce)  of 
glucose  may  be  dissolved  in  1  liter  (quart)  of  normal  salt  solution  or 
in  water  may  be  utilized  for  this  purpose.     (See  Acidosis.) 

In  general,  the  following  plan  may  be  adopted  with  satisfactory 
results  in  all  cases  where  an  anesthetic  is  to  be  administered  and  cir- 
cumstances permit  it  to  be  carried  out.  The  day  preceding  the 
operation  the  patient  should  keep  quiet ;  the  bowels  should  be  thor- 
oughly emptied  by  means  of  a  saline,  and  the  diet  should  be  light  and 
easily  digestible.  The  supper  should  be  a  light  one,  and  nothing  but 
water  should  be  given  for  six  hours  at  least  before  operation  if  pos- 
sible; but  water  may  be  given  freely  up  to  the  time  of  operation. 
At  the  time  of  anesthesia  the  stomach  shmdd  he  empty!    This  has  a 


DIET  AFTER  OPERATION  703 

tendenc}'  to  lessen  tlie  nausea  that  is  apt  to  follow  the  operation,  and 
prevents  vomiting  while  the  operation  is  in  progress.  If  the  stomach 
contains  food  and  vomiting-  occurs,  the  vomited  material  may  be  drawn 
into  the  larynx  and  cause  choking  or  severe  coughing,  or  it  may  be 
drawn  into  th^  lungs  and  cause  pneumonia.  The  vomiting  and. 
coughing  may,  besides,  interfere  materially  with  the  progress  of  the 
operation. 

If  it  is  necessary  to  administer  an  anesthetic  after  a  full  meal  and 
circumstances  permit,  an  emetic  may  be  given  to  empty  the  stomach 
before  operation  is  begun,  or  it  may  be  better  to  wash  out  the 
stomach. 

Nausea  is  apt  to  follow  after  anesthesia,  particularly  after  the  ad- 
ministration of  ether;  this  has  been  discussed  in  a  previous  paragraph. 
Food  should  not  be  hurried  after  an  operation.  A  patient  suffers  less 
from  too  little  food  than  too  much.  If  nausea  does  not  occur,  a  cup 
of  weak  tea  or  of  diluted  milk  may  be  given  two  or  three  hours  after 
the  operation,  and  if  that  is  retained,  milk  may  be  given  as  often  as 
every  three  hours  if  desired.  For  supper,  bread  and  milk  or  cocoa 
or  a  slice  of  toast  and  a  cup  of  tea  may  be  allowed.  It  is  well,  how- 
ever, to  wait  until  the  following  day  before  giving  anything  more.  On 
the  following  day,  if  there  is  no  nausea  or  other  untoward  symptoms, 
a  light  breakfast  may  be  given,  and  after  that  as  rapid  a  return  to 
an  ordinary  diet  as  circumstances  will  allow  may  be  made. 

DIET  AFTER  OPERATION 

There  are  many  erroneous  views  concerning  the  diet  suitable  after 
operations.  These  views  are  held  not  only  by  many  surgeons  of  large 
practice,  but  by  physicians  and  hospital  men  as  well.  Fortunately, 
the  day  is  passing  when  the  surgeon  considers  his  duty  done  when 
he  removes  his  operating  gown.  There  are  still  hospitals,  however, 
where  much  of  the  after-treatment  of  operations  is  delegated  to  un- 
trained men,  who,  often  fresh  from  the  lecture-room,  are  uncertain  as 
to  what  diet  the  patient  should  receive,  and  therefore  leave  this  en- 
tirely to  the  nurse. 

The  diet  following  operations  should  be  supervised  by  the  surgeon 
himself  or  by  an  assistant  who  has  been  especially  trained  for.  the  pur- 
pose. In  operations  about  the  mouth,  as  for  harelip,  and  on  the 
alimentary  tract,  the  management  of  the  diet  is  often  of  as  much 
importance  as  the  operation  itself.  Hans  Kehr  maintains  that  the 
diet  is  as  important  a  part  of  the  technic  after  operations  as  the  steril- 
izing of  hands  and  instruments  is  before  it.  On  account  of  the  diffi- 
culty of  maintaining  a  proper  diet  at  home,  owing  to  the  interference 
of  well-intentioned  but  misguided  friends,  he  refuses  to  operate  at  the 
home  of  the  patient  except  when  transportation  is  out  of  the  question. 

It  should  be  remembered  that  confinement  to  bed  for  weeks  after 
an  operation  greatly  impairs  the  nutrition,  and  every  etfort  should 


704  THE  DIETETIC  MANAGEMENT  OF  SUKUIVAL  CASEi^ 

therefore  be  made  to  select  operations  that  reduce  the  period  of  con- 
finement to  bed  as  much  as  possible.  The  patients  should  be  allowed 
to  get  up  as  soon  as  practicable,  if  only  to  sit  in  a  wheel-chair,  and  so 
make  airing  more  easy.  jNIany  ingenious  devices  have  been  invented 
for  maintaining  comfortable  positions  and  at  the  same  time  permitting 
the  patient  to  be  moved  about.  The  Gatch  bed  is  devised  to  allow  the 
patient  to  change  his  position  and  gives  great  comfort  on  this  ac- 
count. In  some  cases  massage  and  electricity  may  be  employed,  and 
whenever  it  is  possible  the  patient  should  be  in  the  fresh  air  a  part 
of  the  time.  Wherever  feasible  the  bed  maj'  be  rolled  to  a  sun  parlor 
or  to  a  porch  to  supply  the  necessary  light  and  air.  When  this  is 
done  marked  improvement  in  the  nutrition  of  the  patient  follows. 

In  patients  who  are  up  and  about  no  especial  diet  is,  as  a  rule, 
necessary,  except  after  operations  on  the  mouth,  larynx,  or  ali^ 
mentary  tract.  The  diet  should  be  as  simple  and  m^tritious  as  pos- 
sible— usually  that  of  the  ordinary  individual.  Diabetics  do  best 
on  the  diet  advised  for  diabetes,  and  on  such  a  diet  healing  may  be 
facilitated,  whereas  on  an  ordinary  diet  it  may  progress  but  slowly 
or  not  at  all.  Gouty  and  dyspeptic  patients  should  receive  especial 
attention,  as  has  been  directed  in  a  previous  section.  Vegetarians 
should  graduall.y  be  returned  to  a  mixed  diet — indeed,  a  few  weeks' 
stay  in  a  hospital  may  serve  to  cure  them  from  the  folly  of  pursuing 
such  a  diet.  Children  should  be  fed  as  directed  in  the  section  on 
the  Feeding  of  Infants  and  Children,  and  in  all  cases,  where  the  con- 
dition permits,  the  child  should  be  accustomed  to  the  diet  of  the  hos- 
pital before  the  operation,  or  the  results  of  improper  feeding  may  be 
wrongly  attributed  to  the  operation  and  much  harm  result. 

In  all  eases  the  individual  should  be  carefully  studied  as  regards 
his  habits  and  nutrition.  It  is  surprising  to  see  how  the  condition 
improves  and  the  appetite  returns  when  the  patient  is  properly  fed. 

Those  habituated  to  the  daily  use  of  alcohol  for  years  should  re- 
ceive a  moderate  average  amount,  lest  nutrition  be  interfered  with  or 
delirium  develop.  The  amount  should  be  the  minimum  required  to 
secure  results,  but  should  not  be  so  low  as  to  defeat  the  purpose  for 
which  it  is  given. 

Diet  after  Operations  about  the  Head. — Following  all  injuries 
or  operations  about  the  head  the  diet  should  be  carefully  regulated. 
For  the  first  few  days  the  diet  should  be  light  if  the  brain  has  been 
affected — usually  liquid — and  as  nutritious  and  as  easy  of  digestion 
as  it  is  possible  to  make  it. 

The  bowels  should  be  kept  open.  No  alcohol  should  be  allowed 
except  in  the  case  of  habitues,  and  these  should  receive  the  minimum 
amount  based  on  their  previous  daily  average.  If  the  patient  is  un- 
conscious or  unable  to  swallow,  he  should  be  fed  with  the  nasal  or 
stomach-tube  or  rectal  feeding  may  be  instituted. 

After  brain  operations,  when  there  are  no  unusual  symptoms,  th^^ 


DIET  AFTEl!  Ol'Eh'ATlOX  70) 

diet  should  be  liquid  for  the  first  two  or  three  days  and  then  a  semi- 
solid or  even  an  easily  digestible  solid  diet  may  be  allowed.  IMilk- 
toast,  junket,  bouillon  and  egg,  soft-boiled  or  poached  eggs,  squab, 
chicken,  and  the  like  are  allowable.  The  diet  should  be  light  but 
sufficient  in  quantity  until  the  patient  is  up  and  about,  when  the 
amount  may  be  increased  until  a  nearly  normal  diet  is  taken. 

In  operations  of  a  plastic  nature  about  the  face,  where  the  taking 
of  food  or  vomiting  is  apt  to  open  the  wound,  the  food  should  be 
given  by  the  rectum  until,  all  danger  of  vomiting  is  past  and  until  the 
patient  can  masticate  or  swallow  without  fear  of  injuring  the  part. 
It  should  be  remembered  that  wounds  about  the  mouth  are  often  very 
easily  pulled  apart. 

Diet  after  Harelip  or  Cleft=palate  Operations. — Following  these 
operations  especial  attention  to  the  diet  is  necessary.  The  child 
should  be  sent  to  the  hospital  several  days  or  even  weeks  before  the 
operation,  in  order  to  accustom  him  to  the  attendants,  to  the  hospital 
feeding,  and.  to  teach  him  to  take  nourishment  from  a  spoon  or  by 
means  of  a  long  medicine-dropper.  If  the  patient  is  an  infant,  it 
should  receive  the  diet  on  which  it  is  increasing  in  weight.  If  breast 
milk  is  to  be-  given,  it  should  be  taken  from  the  breast  wath  a  breast- 
pump  and  fed  to  the  infant  with  a  spoon.  The  greatest  cleanliness 
should  be  observed,  and  the  technic  of  preparing  and  preserving  the 
milk  should  be  carefully  carried  out,  and  only  sterile  food  should  be 
given  for  four  days.  The  infant  should  not  be  allowed  to  suck  too 
soon,  for  fear  of  breaking  open  the  wound. 

In  all  mouth  operations  the  diet  should  consist  of  cold  sterilized 
milk  or  modifications  of  milk  until  solid  food  can  be  taken.  Rectal 
feeding  or  feeding  by  means  of  a  nasal  tube  may  be-  used  as  a  tem- 
porary expedient. 

Diet  after  Esophageal  Operations. — Following  esophagotomy  rec- 
tal feeding  may  be  employed,  or  the  patient  may  be  fed  with  a  nasal 
or  a  stomach-tube  until  he  is  able  to  swallow  without  pain.  The  food 
should  be  of  liquid  or  semisolid  consistence  until  the  wound  has  healed, 
except  when  the  patient  may  be  trusted  to  masticate  all  food  very 
thoroughly.  If  the  food  is  regurgitated  through  the  wound  or  if  it 
passes  out  on  swallowing,  the  feeding  had  better  be  accomplished  by 
means  of  a  tube,  or  rectal  feeding  may  be  instituted  for  several  days. 

Diet  after  Excision  of  the  Larynx. — The  diet  after  this  operation 
is  a  matter  of  great  importance.  Formerly  great  difficulties  were 
encountered,  and  gastrotomy  was  often  resorted  to  as  a  means  of  fur- 
nishing food  to  the  patient.  With  improvement  in  technic  this  may 
now  usually  be  dispensed  with.  (The  student  is  referred  to  the  text- 
books on  surgery  for  an  account  of  the  improved  technic.) 

The  length  of  time  that  must  be  allowed  to  elapse  after  the  opera- 
tion before  the  patient  can  be  permitted  to  swallow  is  dependent  upon 
the  patient's  condition.     Graf  operated  upon  a  patient  who  was  able 

45 


706  THE  DIETETIC  MAyAGEMEyT  OF  iSUmilVAL  CASES 

to  swallow  on  the  day  following  the  operation.  The  length  of  time 
varies  ordinarily  from  four  days  to  eight  weeks  or  longer.  During 
this  time  rectal  feeding  may  be  employed  at  the  outset,  or  the  nasal 
or  the  stomach-tube  may  be  used.  Some  operators  insert  a  tube  in 
the  esophagus  and  allow  it  to  remain  there  for  days.  It  may  be 
passed  through  the  mouth  or  the  nose.  This  method  has  been  strongly 
condemned  and  is  not  in  general  use. 

Diet  after  Operations  about  the  Gall-bladder  or  Liver, — Follow- 
ing operations  upon  the  gall-bladder,  where  a  fistula  has  been  made, 
the  food  should  consist  largely  of  the  proteins  and  carbohydrates. 
The  fats  are  not  well  borne,  and  for  this  reason  it  is  well  to  eliminate 
them  so  far  as  possible  from  the  dietary.  Water  is  the  first  thing  of 
importance  and  should  be  forced.  It  has  been  demonstrated  that  if  a 
patient  suffering  with  gall-bladder  disease  does  not  void  at  least  500 
c.c.  of  urine  in  twenty-four  hours  mental  symptoms  are  almost  certain 
to  develop. 

Diet  after  Operations  about  the  Pancreas. — The  functions  of  the 
pancreas,  with  the  exception  of  furnishing  a  fat-splitting  enzyme,  can 
be  assumed  and  carried  on  by  the  other  glands.  The  diet  does  not 
differ  from  that  advised  for  other  abdominal  operations,  but  it  may 
be  well  to  limit  the  consumption  of  fats.  The  use  of  artificially  pan- 
creatized  food  has  been  suggested.  This  is  a  subject  that  requires 
further  investigation. 

Diet  after  Operations  about  the  Kidney. — In  all  operations  about 
the  kidney  the  diet  should  be  so  arranged  as  to  make  the  work  of 
elimination  as  easy  as  possible  for  the  organ.  This  may  be  accom- 
plished by  a  diet  such  as  has  been  prescribed  in  chronic  or  even  in 
acute  nephritis.  All  irritating  substances,  in  particular,  should  be 
avoided. 

Diet  after  Operations  on  the  Stomach. — In  preparing  patients 
for  operations  on  the  stomach  the  fact  that  such  individuals  are  often 
emaciated  and  w^eakened  by  long-continued  illness  must  constantly 
be  borne  in  mind ;  on  this  account  such  patients  should,  wherever  pos- 
sible, be  "built  up"  for  at  least  a  week  before  operation.  In  order 
to  accomplish  this  result  as  much  digestible  food  as  the  patient  can 
consume  should  be  given  him.  It  should  be  offered  to  him  in  as  appe- 
tizing and  in  as  concentrated  a  form  as  possible;  as  a  rule,  onlj^  small 
quantities  at  frequent  intervals  should  be  given. 

If  necessan%  rectal  alimentation  should  be  practised;  in  indi- 
viduals who  are  anemic  and  very  weak,  the  use  of  a  salt  infusion  the 
day  previous  to  the  operation  is  advisable.  In  all  operations  on  the 
stomach  it  is  most  important  that  the  organ  be  as  sterile  as  possible, 
and  also  entirely  empty  before  the  operation.  Since  the  noteworthy 
experiments  of  Gushing  and  Livingood,^  by  which  these  investigators 

1  Johns  Hopkins  Hospital  Reports,  vol.  ix. 


DIET  AFTER  OI'E NATION  707 

established  the  fact  that  an  amicrobic  state  can  be  produced  in  the 
stomach  and  small  intestine,  Finney,  as  well  as  other  surgeons,  has 
taken  advantage  of  this  fact  in  his  surgical  procedures  on  the 
stomach. 

By  washing  out  the  stomach  thoroughly  with  sterile  water  twice 
daily  and  feeding  the  patient  on  a  sterile  diet  the  stomach  may  be 
kept  free  from  micro-organisms.  Finney  advises  the  following  pro- 
cedure : 

"For  three  to  four  days  preceding  the  operation  the  patient  is  fed 
on  sterile  liquid  food  at  intervals  of  two  hours.  The  food  is  served 
in  sterile  dishes.  Always  before  taking  nourishment  the  mouth  is 
thoroughly  cleansed  with  a  1  per  cent,  solution  of  carbolic  acid.  The 
stomach  is  washed  twice  daily  with  sterile  water  and  always  two 
hours  before  operation,  and  nothing  allowed  after  this. 

"For  two  days  after  the  operation  nourishment  is  administered 
only  by  means  of  rectal  alimentation.  Normal  salt  solution  enemata 
are  alternated  with  nutrient  enemata  at  intervals  of  every  four  hours, 
or  continuous  feeding  by  the  drop  method  may  be  practised ;  on  the 
third  day  after  operation  egg-albumin  is  given  in  teaspoonful  doses, 
gradually  increased  to  one-half  ounce  every  two  hours,  if  well  borne, 
and  finally  to  one  ounce  every  two  hours  on  the  fourth  day,  and  two 
ounces  on  the  fifth  day.  On  the  eighth  day  any  liquid  is  permissible, 
and  on  the  eleventh  day  the  patient  is  given  a  soft-boiled  egg ;  on  the 
thirteenth,  a  soft  diet ;  on  the  fifteenth,  very  restricted  light  diet ;  on 
the  sixteenth,  a  restricted  light  diet ;  and  on  the  eighteenth,  very  light 
solid  food." 

Surgeons  differ  markedly  in  their  views  regarding  the  time  that 
should  be  allowed  to  elapse  after  operations  on  the  stomach  before 
mouth-feeding  is  begun.  Some,  as  Czerny,  allow  eight  days  to  elapse, 
whereas  others,  as  von  Eiselberg,  give  very  light  food,  such  as  milk,  the 
day  following  the  operation.  According  to  Kehr,^  the  following  regu- 
lations as  to  diet  should  be  maintained  after  operations  on  the 
stomach : 

"1.  After  operation,  the  diet  should  be  regulated  at  first  from 
hour  to  hour,  then  from  day  to  day. 

"2.  Strong,  healthy  individuals  may  be  allowed  to  go  without  food 
as  long  as  their  general  condition  warrants  it. 

"3.  The  more  extensive  the  operation,  the  more  care  should  be 
exercised  with  the  diet. 

"4.  Patients  weakened  by  cancerous  growths  may  be  allowed  liquid 
food  as  soon  as  the  effect  of  the  anesthetic  has  worn  off. 

"5.  An  exact  knowledge  of  the  motor  as  well  as  the  secretory  func- 
tions of  the  stomach  will  indicate  the  proper  method  of  feeding  in 
these  cases." 

1  Leyden's  Handbuch  der  Erniihrungs-Therapie,  2d  edition,  vol.  ii,  p.  555. 


708  THE  DIETETIC  MAXAGEME^T  OF  ULRUIVAL  CASES 

FINNEY  AND  FRIEDENWALD'S  DIET  LIST  FOLLOWING  OPERATIONS 

ON  THE  STOMACH 

First  day,  nothing  by  mouth;  nutiient  enemata  every  4  hours,  alternating  with 
continuous  salt  solution  by  ]Murpiiy's  method. 

'Second  day,  increase  water  irom  one  dram  gradually  to  1  ounce  every  two 
hours. 

Third  day,  water,  1  ounce,  alternating  with  albumin,  1  dram. 

Fourth  day,  increase  albumin  to  one  ounce. 

Fifth  day,  water  two  ounces  every  two  hours  alternating  with  albumin  two 
ounces. 

Sixth  day,  water  four  ounces  every  two  hours  alternating  with  albumin  two 
ounces. 

Seventh  day,  water  ad  libitum;  albumin  two  ounces  every  two  hours. 

Eighth  day,  any  liquid,  2  ounces  every  two  hours. 

Ninth  day,  any'liquidy  3  ounces  every  "two  hours. 

Tenth  day,  any  liquid,  4  ounces  every  two  hours  (discontinue  rectal  feeding). 

Eleventh  day,  one  soft  boiled  egg  in  addition  to  any  liquid. 

Twelfth  day",  two  soft  boiled  eggs  in  addition  to  any  liquid. 

Thirteenth  day,  soft  diet. 

Fourteenth  day,  soft  diet. 

Fifteenth  day,  very  restricted  light  diet. 

Sixteenth  day,  restricted  light  diet. 

Seventeenth  day,  restricted  light  diet. 

Eighteenth  day,  any  digestible  solid  food. 

After  the  eighteenth  day  the  following  diet  list  may  be  gradually  followed,  and 
should  be  continued  for  at  least  four  or  five  months:  Soups:  any  light  soup. 
Meats;  any  of  the  easily  digestible  meats,  as  brains,  sweetbreads,  beef,  mutton, 
lamb,  or  poultry  (best  minced,  and  taken  either  broiled  or  boiled).  Fish:  mainly 
the  white  variety,  mackerel,  rock  bass,  as  well  as  oysters  (boiled  or  broiled). 
Eggs;  in  any  form  except  fried.  Vegetables;  best  taken  mashed  and  strained; 
the  easily  digestible  forms  as  asparagus,  spinach,  peas,  beans,  potatoes,  carrots. 
Farinaceous  food:  any  of  the  cereals;  bread  to  be  taken  stale.  Desserts;  any 
of  the  light  puddings.  Fruits;  mainly  stewed.  Fatty  food;  cream,  butter  and 
olive  oil.  Drinks;  milk,  buttermilk,  cocoa,  carbonated  mineral  waters  and  plain 
water. 

The  following  must  be  avoided :  Rich  soups,  fried  foods,  pork,  veal,  stews, 
hashes,  corned  meat,  potted  meat,  twice  cooked  meat,  liver,  kidney,  duck,  goose, 
sausage,  crabs,  sardines,  lobster,  preserved  fish,  smoked  fish,  salted  fisli,  salmon, 
cauliflower,  celery,  radishes,  cabbage,  cucumbers,  sweet  potatoes,  tomatoes,  beets, 
corn,  salads,  bananas,  melons,  berries,  pineapple,  hot  bread,  or  cakes,  nuts,  can- 
dies, pies,  pastry,  preserves,  cheese,  strong  tea,  strong  coffee,  alcoholic  stimulants. 

Diet  after  Operations  on  the  Intestine. — In  operations  on  the 
upper  portion  of  the  intestine  the  dietetic  regulations  are  similar  to 
those  previously  described  under  Operations  on  the  Stomach;  food 
may,  however,  be  given  by  the  mouth  earlier  than  after  operations  on 
the  stomach.  The  food  should  be  of  such  a  nature  as  will  not  leave 
too  solid  a  residue  in  the  bowels ;  it  must  also  vary  according  to  the 
pathologic  condition  present,  as  well  as  according  to  the  extent  of  the 
surgical  procedure. 

After  an  ordinary  appendix  operation  the  patient  may  be  given 
liquid  food  on  the  second  day  after  operation ;  on  the  third  day  a  soft 
diet  may  be  allowed,  and  on  the  fifth  or  sixth  day  solid  food  may  be 
taken;  on  the  other  hand,  if  the  operation  has  been  a  serious  one,  with 
pus-formation  and  a  gangrenous  appendix,  he  may  be  required  to  be 
fed  exclusively  by  rectal  enemata  for  five  or  six  days  or  more,  and 


D1F.T  M'TEIi  Ol'Eh'ATJOX  709 

then  liciuids  given,  but  milk  should  not  be  allowed  for  some  days,  until 
the  other  liquids  are  borne  without  difficulty. 

The  cause  of  death  after  gastric  and  intestinal  operations,  accord- 
ing to  F.  Ehrlich,^  is  not  so  much  shock  as  exhaustion,  brought  en 
by  starvation  before  and  after  the  operation.  To  prevent  this  he 
feeds  his  patients  immediately  after  the  ether  nausea  has  worn  off, 
and  he  feeds  them  well. 

He  feeds  his  patients  by  a  routine  method  in  the  following  manner : 
So  soon  as  the  nausea  from  the  anesthetic  has  worn  oif,  the  patient 
gets  tea,  red  wane  or  gruel ;  on  the  day  after  tlie  operation  he  is  given 
sweetbread  in  bouillon,  even  if  it  nauseates  him ;  if  the  nausea  is  per- 
sistent his  stomach  is  washed.  On  the  second  day,  finely  chopped, 
cooked  squab,  chicken  or  veal  is  added ;  on  the  third  day,  beef,  potato 
puree,  and  cakes;  on  the  fourth,  chopped  ham  (raw),  soft  zwieback, 
and  soft-boiled  eggs  •,  on  the  fifth  day,  white  bread  and  spinach.  After 
the  seventh  day  the  meat  is  not  chopped  and  then  the  patient  returns 
gradually  to  normal  diet.  Tiie  bowels  are  regulated  with  oil  enemas. 
The  shock  of  the  operation  does  not  usually  last  beyond  the  third  day. 

After  operations  on  the  rectum  the  patient  is  kept  on  a  fluid  diet 
for  from  four  to  five  days ;  after  this  a  soft  diet  is  given,  and  finally, 
in  six  or  seven  days,  solid  food  may  be  prescribed. 

Feeding  through  Gastric  or  Intestinal  Fistulas. — After  gastric  or 
intestinal  fistulas  have  been  made,  the  patient  may,  if  necessary,  be 
fed  through  these  openings  as  early  as  a  few  hours  after  the  operation. 
It  is  best  at  first  to  give  only  very  small  quantities  of  liquids  at  fre- 
quent intervals.  Kehr  advises  alternately,  every  two  hours,  one-half 
cup  of  tea  with  cognac,  milk,  and  egg,  and,  on  the  second  day,  wine 
with  peptone.  He  adds  bouillon  with  an  egg  on  the  third  day,  and 
begins  with  "mushy"  food,  such  as  potato  soup,  flour  soups  with  egg, 
beef-tea  with  minced  breast  of  chicken  on  the  eighth  day.  After 
three  w-eeks  the  patient  may  be  allowed  to  masticate  his  food,  and  then, 
by  means  of  a  rubber  tube,  pass  it  into  the  stomach  through  the  fistula. 

Diet  in  Pancreatic  Fistula. — Heineke  has  pointed  out  that  in  per- 
sistent fistula  following  operation  on  the  pancreas,  where  there  is 
maceration  of  the  skin  due  to  the  action  of  the  pancreatic  secretion, 
Wohlgemuth 's  method  of  dieting  gives  satisfactory  results.  Wohl- 
gemuth found  that  the  amount  of  fluid  discharged  from  the  pancreas 
depended  on  the  composition  of  the  food  taken  by  the  patient.  With 
fatty  diet  the  secretion  was  very  scanty,  and  with  an  albuminous  diet 
it  increased  on  the  addition  of  carbohydrates  and  became  very  abun- 
dant. Secretion  is  increased  by  acids  and  diminished  by  alkalis.  Bi- 
carbonate of  soda  in  small,  frequently  repeated  doses  is  perhaps  the 
best  method  of  administering  alkalis  in  these  cases. 

1  Miinchener  Medinische  Wochenschrift,  1904,  ii.,  614,  No.  14. 


ARMY  AND  NAVY  RATIONS 
ARMY  RATIONS 

By  the  term  "ration"  is  meant  the  sum-total  of  the  daily  allow- 
ance of  food  issued  by  a  government  to  its  soldiers  and  sailors. 
Candles  and  soap  also  form  part  of  the  ration.  Computation  of  the 
quantities  of  the  various  component  parts  of  the  ration  is  greatly 
facilitated  by  the  use  of  the  "Army  Kation  Issue  and  Conversion 
Tables,"  Avhich  show,  almost  at  a  glance,  the  amounts  required  for 
any  number  of  rations  from  1  to  50,000. 

The  subject  of  army  rations  has  received  careful  study.  The  sub- 
joined tables,  taken  for  the  most  part  from  articles  on  army  diet  by 
Major  Charles  E.  Woodruff,  of  the  United  States  Army,  give  a  sum- 
mary of  the  rations  furnished  the  various  armies  of  the  world. 

The  ration  in  times  of  peace  is  easily  arranged.  Whether  or  not 
the  soldier  is  well  fed  will  depend  largely  on  the  commander  and  the 
cook  of  the  compam^  Each  soldier  is  required  to  do  his  own  cook- 
ing, except  in  garrisons,  when  certain  men  are  detailed  for  that  duty, 
[f  the  cook  is  energetic  and  skilful,  he  will  be  able  so  to  arrange  the 
diet  as  to  give  the  men  sufficient  variety;  if,  in  addition  to  the 
regular  ration,  there  are  a  kitchen-garden  at  the  army  post  and  a 
well  managed  "savings  fund,"  the  company  should  live  very  well 
indeed.  On  the  other  hand,  if  the  cook  is  unskilful  or  lazy,  and  if 
there  is  neither  kitchen-garden  nor  savings  fund  to  draw  upon,  the 
company  will  receive  a  monotonous  or  even  an  injurious  diet.  The 
"savings  fund"  is  made  up  of  the  money  obtained  from  the  sale  of 
unused  rations.  That  part  of  the  ration  which  is  not  utilized  is  re- 
sold to  the  commissary,  and  the  money  so  obtained  is  expended  by 
the  commander  of  the  company  for  table  luxuries.  The  fund  is  aug- 
mented by  the  profits  of  the  "Post  Exchange,"  which  is  a  sort  of 
general  store  where  tobacco,  lunches,  and  the  like  are  sold.  The 
amount  and  variety  of  food  supplied  are  set  forth  in  the  following 
tables,^  compiled  hj  Woodruff  from  observations  made  by  him  at 
Fort  Assiniboine,  Montana : 

Percentage  of  Waste. 

Bacon    1 .40 

pi  8  no  f  ^^^^y  ^  pounds  were  reported,  but  this  was  in- 

"I    creased  in  31  pounds,  to  include  bones,  etc. 

Bread    3.30  ^   Crusts  and  small  unavoidable  wastes. 

Beef     22.50      191  bone,  2|  fat.  and  other  wastes. 

1  Woodruff,  The  Journal  of  the  American  Medical  Association,  December  3,  1892, 
p.  651. 

710 


A  A' MY  KATIOSii 


711 


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Potatoes   27.09 

Onions     21.04 

Prunes    33.00 

Cabbage    45  00 

Ham    12.00 


Parings  and  defective  ones. 
Stones  and  other  wastes. 


Estimated. 


712 


ARMY  ASD  NAVY  RATI  ON  ti 


Additional  Articles  Consumed. 

Daily  per 

man.  Allowance. 

338  lbs.  green   coffee    ..1.23    ounces.   1.60  ounces. — Or 

8  lbs  tea   0.03    ounce.     0.32 

C  Allowance  is   large  to  allow 


20  gallons  vinegar    .  .  .0.14    gill         0.32  gill  .  . 

10  lbs.  pepper    0.030  ounce.     0.04  ounce.. 

11  bottles  Havering  extract 
3  lbs.  mustard. 

24  lbs.  baking-powder. 
G  lbs.  currants. 
5  gallons  pickles. 


4  kegs  pickled  pigs'  feet 


J  of  making  a  saving  to  be 
I  used  in  making  sauerkraut 
[    and  pickles  in  the  fall. 


Though  containing  much 
energy,  it  is  omitted  because 
composition  is  unknown, 
and  the  actual  amount  per 
man  is  very  small. 


80    per    cent,    of   vegetables. 
20    2)er    cent,    of   vegetables. 


Consumption  and  Allowance  per  Man. 

Daily  per 

man.  Allowance. 

4379  lbs.  flour   l.i.Dl  ounces.  18     ounces.      Includes  purchases. 

4946i   lbs.  bread    17.97        "  IS 

3431  lbs.  pork    1..34       "  1.2       " 

273  J  lbs.  bacon    1.00  ounce.  2.4       " 

502.5   lbs.   beef    18.30  ounces.  18.0 

5116  lbs.  potatoes    18..50       "  12.8 

700   lbs.   onions    2.50       "  3.2       " 

428i   lbs.  beans    1.50       "  2.4 

763  lbs.  sugar   2.70       "  2.4       " 

64  lbs.  butter 2.00       "  .  . 

137  lbs.  lard   0.50       " 

15  gallons  syrup   0.40  gill. 

A  ration  is  the  allowance  for  the  subsistence  of  one  person  for  one 
day.  The  garrison  ration  is  intended  for  troops,  whenever  prac- 
ticable, in  time  of  peace,  also  in  time  of  war,  except  for  those  beyond 
the  advance  depots ;  the  haversack  ration  is  intended  for  troops  be- 
yond the  advance  depots ;  the  travel  ration  is  for  troops  traveling 
otherwise  than  by  marching,  and  separated  from  cooking  facilities; 
the  Filipino  ration,  for  the  use  of  Philippine  scouts ;  and  the  emer- 
gency ration,  for  troops  in  active  campaign,  for  use  on  occasions  of 
emergency  or  in  the  field  for  purposes  of  instruction. 

The  commanding  officer  will  determine  which  of  the  several  pre- 
scribed rations  is  appropriate  for  the  particular  service  to  be  per- 
formed, and  will  direct  the  use  of  the  same. 

When  in  the  exigencies  of  the  service  troops  are  subsisted  on  the 
haversack  ration,  and  it  is  found  to  be  practicable  to  supplement 
these  stores  by  local  purchases  or  by  shipments,  the  commanding 
general  may  direct,  in  written  orders,  the  issue  in  kind,  in  addition 
to  the  haversack  ration,  of  such  available  articles  of  food  not  in 
excess  of  the  amounts  allowed  of  corresponding  articles  in  the  gar- 
rison ration. 


AKMY  KATIO\S 


713 


The  United  States  is  the  only  nation  that  furnishes  the  entire  ra- 
tion to  the  soldiers.  The  following  tables  were  taken  from  the  general 
orders,  No.  60,  of  the  United  States  War  Department,  issued  May  8, 

1.   Garrison  Ration. 


Component  articles  and 
quantities. 


Substitutive  articles  and  quantities. 


Beef,  fteeh 


Flour 

Baking  powder , 
Beans 


Potatoes  ' 


Prunes 


Cinnamon 


Lard 

Butter 

Syrup 

Flavoring   ex- 
tract, lemon 


20  ounces 


18  ounces 


0.08  ounce. 
2  4  ounces 


20  ounces 


Coffee,   roasted    ) 
and  ground  .  .  / 

Sugar     

Milk, evaporated.  1 
unsweetened     j 

Vinegar 


Salt 

Pepper,  black . 


1.28  ounces 


1.12  ounces 


3.2  ounces 
0.5  ounce 

0  16  gill  . 

0  64  ounce 
0.04  ounce 


0.64  ounce. 
0  5  ounce  .   . 
0,32  gill  . 

0.014  ounce 


Mutton,  fresh 

Bacon'     

Canned  meat,  when  impracticable 
to  furnish  fresh  meat      . 

Hash,  corned  beef,  when  impracti- 
cable to  furnish  fresh  meat  .... 

Fish,  dried 

Fish,  pickled 

Fish,  canned .   . 

Turkey,  dressed,  drawn,  on  Thanks- 
giving Day  and  Christmas,  when 
practicable 

Soft  bread     

Hard  bread,  to  be  ordered  issued 
only  when  the  interests  of  the  gov- 
ernment so  require 

Corumeal 


20  ounces. 
12  ounces. 

16  ounces. 

16  ounces. 
14  ounces. 
18  ounces. 
16  ounces. 


16  ounces. 
18  ounces. 


16  ounces. 
20  ounces. 


0.014  ounce  . 


f  Rice      

I  Hominv   .   .  

Potatoes,  canned 

Onions,  in  lieu  of  an  equal  quantity 
of  potatoes,  but  not  exceeding  20 
per  cent,  of  total  issue. 

Tomatoes,  canned,  in  lieu  of  an  equal 
quantity  of  potatoes,  but  not  ex- 
ceeding 20  per  cent,  of  total 
issue. 

other  fresh  vegetables  (not  canned) 
when  they  can  be  obtained  in  the 
vicinity  or  transported  in  a  whole- 
some condition  from  a  distance,  in 
lieu  of  an  equal  quantity  of  pota- 
toes, but  not  exceeding  30  per  cent, 
of  total  issue. 

Apples,  dried  or  evapor%ted 

Peaches,  dried  or  evaporated  .  .  .  . 

Jam,  in  lieu  of  an  equal  quantity  of 
prunes,  but  not  exceeding  50  per 
cent,  of  total  issue. 
'  Coffee,  roasted,  not  ground 

Coffee,  green  . 

Tea,  black  or  green 


(  Pickles,  cucumber,  in  lieu  of  an  equal 
-;  (juantity  of  vinegar,  but  not  exceed- 
(.    ing  50  per  cent,  of  total  issue. 


Cloves  . 
Ginger  . 
Nutmeg 


Oleomargarin . 


1.6  ounces. 
16  onncpa 
15  ounces. 


1.28  ounces. 
1.28  ounces. 


1 12  ounces. 
14  ounces. 
0.32  ounce. 


0.014  ounce. 
0.014  ounce. 
0.014  ounce. 


0.5  ounce. 


Vanilla 0.014  ounce. 


1  In  Alaska,   16  ounces   oacon,  or,  when  desired,   16  ounces   salt  pork,  or   22 
ounces  salt  beef. 

2  In  Alaska  the  allowance  of  fresh  vegetables  will  be  24  ounces  instead  of  20 
ounces,  or  canned  potatoes,  18  ounces  instead  of  15  ounces. 

Note — Food  for  troops  traveling  on   United   States  Army  transports  will   be 
prepared  from  the  articles  of  subsistence  stores  which  compose  the  ration  for 


714 


ARMY  ASD  XAVY  RATIONS 


1911.     There  are  very  slight  changes  from  the  rations  as  given  in 
our  previous  editions: 

"The  kinds  and  quantities  of  the  component  articles  of  the  army 
ration  and  the  substitutive  equivalent  articles  which  may  be  used  in 
place  of  such  components  shall  be  as  follows: 


Haversack  or  Reserve  Ration. 


Component  articles  and 
quantities. 


Bacon il2  ounces 

or  meat  canned.   16  ounces  . 
Hard  bread  .16  ounces 

Coffee,  roasted     V^^^  ounces 
and   ground  .  j 

Sugar 2  4  ounces 

Salt 0.16  ounce 


Substitutive  articles  and  quantities. 


3.   Travel  Ration. 


Component  articles  and 
quantities. 


Substitutive  articles  and  quantities. 


Soft  bread  ....  18  ounces  . 
Beef,  corned  .  .  .12  ounces  . 
Beans,  baked  .  .  I  4  ounces  . 
Tomatoes,  canned  \  8  ounces  . 
Jam 1.4  ounces 

"^^nTgroundM  1-12  ounces 

Sugar 12.4  ounces 

Milk.evaporated, )  In  t  „,,„,,- 
unsweetened  .)  1°-^  o"^*'^- 


Hard  bread 16  ounces. 

Hash,  corned  beef 12  ounces. 


4.  Filipino  Ration. 


Component  articles  and 
quantities. 


Substitutive  articles  and  quantities. 


Beef,  fresh 


12  ounces  . 


Flour 18  ounces  . 

Baking    powder,"!  | 

when   in   field  I  '„  go  „„„„. 

and  ovens  are    ^'^  o"°ce 

not  available  .  j  : 
Rice,  unpolished  .  120  ounces  . 

Potatoes I  8  ounces  . 

Coffee,  roasted     )  |  ,  „„„„„ 

and   ground  .  \\^  ''"^^^  " 

Sugar ;  2  ounces 

Vinegar '0.08  gill  .   . 

Salt 10.64  ounce 

Pepper,  black .  .  .  '0.02  ounce 


Bacon 18  ounces. 

Canned  meat i  8  ounces. 

Fish,  canned jl2  ounces. 

Fish,  fresh '12  ounces. 

Hard  bread 8  ounces. 


Soft  bread 


Onions 


8  ounces. 


8  ounces. 


troops  in  garrison,  varied  by  the  substitution  of  other  articles  of  authorized  sub- 
sistence stores,  the  total  cost  of  the  food  consumed  not  to  exceed  24  cents  per  man 
per  day,  except  on  Thanksgiving  Day  and  Christmas,  when  not  to  exceed  39 
cents,  is  authorized. 


AKMl    KATW.SS  715 

"One  day  in  each  alternate  month  of  the  season  of  practical  in- 
struction, not  exceednig  three  days  in  eacli  year,  the  use  of  the  haver- 
sack ration  with  individual  cooking  will  be  required  by  all  troops  in 
the  tield  for  purposes  of  instruction. 

"Scout  organizations  will  be  required  to  use  the  entire  allowance 
of  the  meat  component,  and  not  more  than  16  ounces  of  rice  per  day 
to  be  used  for  each  ration.  The  purchase  of  1.6  ounces  of  beans  per 
ration  in  substitution  of  the  portion  of  the  rice  ration  not  drawn  will 
be  made,  and  use  of  as  large  an  extent  as  possible  of  native  products, 
such  as  camotes,  mangoes,  and  squash,  will  be  required." 

The  food  supplied  the  soldiers  in  training  at  the  cantonments  has 
been  made  the  subject  of  a  short  study  by  IMurlin  (Science,  May  24, 
1918,  p.  495).  On  an  average  routine  the  8,700  calories  were  actu- 
ally consumed,  while  the  average  soldier  of  five  feet,  eight  inches,  carry- 
ing his  equipment  and  walking  at  the  rate  of  three  miles  an  hour 
reciuired  4,100  for  a  thirty  mile  walk.  For  faster  rates  the  amount 
of  food  needed  rapidly  increased.  The  following  figures  on  page  716 
show  the  nature  and  amount  of  food  actually  used. 

It  is  interesting  to  compare  the  above  with  the  rations  supplied  the 
Allies.     The  table  on  page  717  is  taken  from  Murlin's  article: 

Concerning  the  selection  of  a  ration  Woodruff  says:  "An  army 
must  be  fed  at  a  great  distance  from  the  market,  and  it  is  therefore 
evident  the  chief  objects  in  view  in  the  selection  of  the  soldier's  food 
must  be  facility  of  transportation  and  ease  of  preservation  in  all 
climates.  Articles  that  are  bulky  or  easily  damaged  by  rough  han- 
dling, and  those  that  are  not  easily  preserved  from  decay,  are  at  once 
ruled  out.  It  need  scarcel.y  be  mentioned  that  the  articles  must  be 
produced  in  abundance  throughout  the  country,  neither  imported 
nor  the  particular  preparations  of  a  few  manufacturers.  Couple 
with  this  the  fact  that  the  articles  must  be  so  inexpensive  as  to  refute 
any  charges  of  extravagance,  and  it  will  be  readily  understood  that 
with  a  few  exceptions  the  ration  contains  about  all  the  articles  that 
it  is  possible  to  put  in  at  present  without  calling  on  foods  that  are 
preserved,  canned,  or  otherwise  specially  prepared." 

For  the  reasons  just  stated  Woodruff  says  that  the  soldier's  ration 
has  always  been  simple  and  dry.  There  was  but  little  change  in  the 
army  ration  until  recent  years.  In  arranging  the  ration  for  an  army 
there  are  a  number  of  matters  that  require  careful  consideration. 
An  army  in  a  cold  climate  can  not  thrive  on  the  same  diet  that  an 
army  in  the  tropics  would  do  well  on,  and  vice  versa.  In  a  cold 
climate  any  article  that  will  be  spoiled  by  freezing  must  be  eliminated 
from  the  dietary.  This  excludes  potatoes,  fresh  vegetables,  canned 
goods  that  are  in  fluid  form,  and  the  like. 

The  subject  of  diet  for  soldiers  in  the  tropics  is  one  of  great  in- 
terest.    Food  that  excessive  heat  will  spoil  or  that  can  not  easily  be 


"16 


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preserved  by  ignorant  men  must  be  avoided.  The  ration  should  be 
so  arranged  that  it  may  readily  be  changed  to  suit  tlie  climate.  It 
has  been  abundantly  proved  by  our  army  in  the  Philippines  that 
men  living  quiet  lives  in  the  tropics  eat  less  than  they  would  in  a 
cold  or  temperate  climate.  This  ditference  is  particularly  marked 
in  the  consumption  of  meat  and  fatty  substances.  If,  however,  an 
army  is  undergoing  very  active  service  with  excessive  labor  and  re- 
sulting fatigue,  the  meat  allowance  will  have  to  be  correspondingly 
increased  to  make  up  for  the  wear  and  tear  of  the  muscular  system. 
Major  Kean  is  quoted  as  follows  in  the  report  of  the  Surgeon-General 
of  the  United  States  Army,  1900,  p.  201 : 

"He  premises  that  a  tropical  dietary,  as  compared  with  one  suited 
to  a  colder  climate,  should  have  less  fat  and  more  carbohydrates,  less 
stimulating  proteins  in  the  form  of  meat,  a  greater  variety  of  diet 
both  of  meats  and  of  carbohydrates  in  the  form  of  fresh  vegetables 
and  fruits,  and,  lastly,  a  fairly  liberal  supply  of  ice.  His  argument 
for  the  substitution  of  carbohydrates  for  fats  is  that  the  digestion  is 
weakened  in  hot  climates  and  the  liver  is  inclined  to  torpidity,  while 
ingested  fats  are  prone  to  split  up  into  butyric,  caproic,  and  other 
irritating  acids,  which  the  diminished  secretion  of  the  liver  is  unable 
to  neutralize.  As  intestinal  digestion  cannot  proceed  in  the  presence 
of  acidity,  the  condition  known  as  biliousness  is  established,  with 
putrefaction  of  the  intestinal  contents  and  the  production  of  various 
harmful  alkaloid  substances.  A  catarrhal  inflammation  of  the  bowel 
results,  with  diarrhea,  which  is  at  first  of  advantage  in  eliminating 
the  harmful  substances,  but  which  under  the  continued  irritation  of 
unsuitable  diet  is  liable  to  continue  and  become  aggravated.  As  to 
a  lessened  use  of  meat,  he  cites  the  dietary  customs  of  the  inhabitants 
of  hot  climates,  who  get  their  proteins  less  from  meat  than  from  the 
leguminosae.  The  appetite  is  lessened  by  long  and  continued  heat  and 
becomes  capricious.  It  craves  variety,  especially  in  vegetables  and 
fruits,  and  these  he  claims  cannot  be  had  on  the  basis  of  our  present 
ration.  The  need  of  ice  to  furnish  a  cool  drinking-water  and  to 
preserve  the  perishable  constituents  of  the  ration  is  regarded  as 
obvious." 

An  admirable  essay  on  "The  Ideal  Ration  for  an  Army  in  the 
Tropics,"  by  Captain  Edward  L.  Munson,  appeared  in  the  Boston 
Medical  and  Surgical  Journal  for  May,  1900.  Munson  thinks  that 
the  present  ration  is  very  well  chosen  as  to  its  nutrient  properties, 
but  that  it  should  be  rearranged  for  use  in  the  tropics,  and  he  sug- 
gests the  following  tables  for  tropical  dietaries: 


ARMY  h'ATIOyS 


719 


Tropical  Dietary  1. 


Articles. 


Quantity, 
ounces. 


Fresh  beef . 
Flour  .  .  . 
Beans ..  .  . 
Potatoes .  . 
Dried  fioiit 
Sugar .    .    . 


10.0 

18.0 

2.4 

16.0 

3.0 

3.5 


Fats, 
grams. 


44.75 
5.60 
1.22 
0.45 
1.53 


Carbo- 
hydrates, 
grams. 


380.46 
40.18 
81.70 
33.80 
94.25 


Total 52.9         53.55     630.39     123.19     18.78 


Protein, 
grams. 


41.68 

55.08 

15.16 

9.50 

1.77 


Nitrogen,!   l^t 
grams 


6.67 
7.90 
2.42 
1.52 
0.27 


value, 
calories. 


590 
1850 
240 
380 
220 
397 

3677 


Total  carbon,  395.14  grams ;  nitrogen  to  carbon,  1 :  19.6. 

The  following-  table  gives  a  proposed  dietary  suitable  for  tlie  tropics, 
and  especially  applicable  to  field  service ;  in  this  the  fatty  constituents 
attain  their  maximum  and  the  potential  energy  is  high : 

Tropical  Dietary  II. 


Articles. 


Quantity, 
ounces". 


Bacon .  -  . 
Hard  bread 
Beans .  .  - 
Dried  fruit 
Sugar .    .    . 


Total 


6.0 
18.0 
2.4 
3.0 
3.5 


32.9 


Fats, 
grams. 


105.06 
6.62 
1.22 
1.53 


Carbo-      !,„„+„;„ 
hydrates,!  ^J"^^'?' 


grams. 


grams. 


371.81 
40.18 
50.70 
94.25 


144.44     556.94     105.69 


15.64 

73.12 

15.16 

1.77 


Nitrogen,!     Fuel" 
g'-^"^^-   i  caforilk. 


2.49 

11.74 

2.42 

0.27 


1042 

1926 

240 

220 

397 


16.92      3825 


Total  carbon,  328.76  grams ;  nitrogen  to  carbon,  1  :  23. 

The  nutrient  value  of  the  ordinary  dietary  as  proposed  for 
garrison  duty  in  the  tropics  is  as  follows  : 

Tropical  Dietary  III. 


Articles. 


Fresh  beef.    ... 

Soft  bread 

Potatoes  and  onions . 
Dried  fruit  .  .  .  . 
Sugar 


Total 


Quantity, 
ounces. 


10.0 

20.0 

16.0 

3.0 

3.5 


52.5 


Fats, 
grams. 


44.75 

6.80 
0.72 
1.53 


Carbo- 
hydrates 
grams. 


299.20 
73.09 
50.70 
94.25 


53.80     517.24     105 


Protein, 
grams. 


41.68 

53.83 

8.60 

1.77 


Nitrogen, 
grams. 


6.67 
8.61 
1.40 
0.27 


Fuel- 
value, 
calories. 


690 
1506 
340 
220 
397 


16.95   3053 


Total  carbon,  328.76  grams ;  nitrogen  to  carbon,  1 :  18. 

For  the  following  combination  the  several  articles  of  the  ration  mo.st 
closel.y  approaching  in  character  the  food  materials  used  by  natives 
of  the  tropics,  proportioned  in  quantity  according  to  the  standard 
proposed  for  hot  climates,  have  been  selected: 


720 


ARMi    ASD  SAVY  KATWMS 
Tropical  Dietary  IV. 


Articles. 

Quantity, 
ounces. 

Fats, 
grams. 

Carbo- 
hydrates, 
grams. 

Protein, 
grams. 

Nitrogen, 
grams. 

Fuel- 
value, 
calories. 

Fresh  fish  (cod),  whole 

Soft  bread 

Eice 

Potatoes  and  tomatoes 
Dried  fruit         .... 
Sugar 

140 

20.0 
4.0 

16.0 
3.0 
3.5 

0.79 
6.80 
0.45 
0.54 
1.53 

299.20 
88.87 
65.80 
50.70 
94.25 

31.73 

53.83 

8.75 

8.17 

1.77 

5.07 
8.61 
1.40 
1.36 
0.27 

120 
1506 
407 
297 
220 
341 

Total 

64.5 

10.11 

698.82 

104.25 

16.71 

2947 

Total  carbou,  327.50  grams ;  nitrogen  to  carbon,  1 :  19.6. 

On  averaging  these  four  dietaries,  as  furnished  by  the  ration  pro- 
posed for  the  tropics,  the  mean  nutrient  composition  is  seen  to  be  as 
follows : 


Dietary. 

Quantity, 
ounces. 

Fats, 
grams. 

Carbo- 
hydrates, 
grams. 

Protein, 
grams. 

Nitrogen, 
grams. 

Fuel- 
value, 
calories. 

I 

II 

Ill 

IV 

Average 

52.9 
32.9 
52.5 
64.5 
50.7 

53.55 
114.44 
53.80 
10.11 
37.97 

630.39 
656.94 
517.24 
698.82 
560.85 

123.19 
105.69 
105.88 
104.25 
109.06 

18.78 
16.92 
16.95 
16.71 
17.34 

3677 
3825 
3053 
2947 
3375 

Total  carbon,  350  grams ;  nitrogen  to  carbon,  1 :  20. 

It  will  be  observed  that  while  these  four  dietaries  differ  consider- 
ably from  one  another,  yet  when  averaged  together  in  equal  propor- 
tions they  do  not  vary  greatly  from  the  nutritive  standard  for  the 
tropics  already  proposed — and  this  is  an  additional  reason  why  the 
same  articles  of  diet  should  not  be  selected  from  day  to  day.  It  is 
seen  that  the  foregoing  average  dietary,  as  compared  with  the  pro- 
posed nutrient  standard,  is  still  slightly  deficient  in  fats  and  fuel- 
value  and  a  trifle  in  excess  as  regards  protein.  These  discrepancies, 
however,  if  they  may  be  considered  as  such,  are  readily  overcome  by 
using  Dietary  II.  twice,  whereas  Dietaries  I.,  III.,  and  IV.  are  each 
employed  but  once.     The  results  of  this  change  are  as  follows  : 


Dietary. 


I.      .    .    . 

n.  .  .  . 
n.  .  .  . 
in.  .  . 
IV. .  .  . 

Average 


Quantity, 
ounces. 

Fats, 
grams. 

Carbo- 
hydrates, 
grams. 

Pijotein, 
grams. 

Nitrogen, 
grams. 

52.9 
32.9 
32.9 
52.5 
64.5 
47.1 

53.55 
114.44 
114.44 
53.80 
10.11 
69.43 

630.39 
556.94 
556.94 
617.24 
598.92 
572.06 

123.19 
105.69 
105.69 
105.88 
104.25 
108.38 

18.78 
16.92 
16.92 
16.95 
16.71 
17.26 

Fuel- 
value, 
calories. 


3677 
3826 
3825 
3053 
2947 
3465 


Total  carbon,  363.33  grams ;  nitrogen  to  carbon,  1 :  21. 


AliMl   h'ATlOXiS  721 

Another  point  to  be  remembered  is  that  if  the  eliange  in  diet  is 
made  gradually,  men  can  be  accustomed  to  live  on  almost  any  food, 
whereas  rapid  changes  in  the  diet  are  not  well  borne  and  are  apt  to 
be  followed  by  illness. 

The  army  ration  should  not  be  planned  with  a  view  to  keeping  a 
soldier  on  the  smallest  possible  amount  of  food  at  the  least  possible 
expenditure  of  money.  His  diet  should  be  such  as  will  maintain  him 
in  the  best  physical  condition,  regardless  of  the  varied  circumstances 
under  which  he  may  be  compelled  to  live.  There  is  no  economy  in 
underfeeding  soldiers.  In  all  wars  the  number  of  sick  and  of  those 
dead  from  disease  due  to  improper  food  is  larger  than  that  due  to  the 
enemj-'s  bullets. 

Many  theories  and  opinions  regarding  what  constitutes  the  best 
food  for  a  soldier  have  been  advanced.  On  one  point,  however,  all 
are  agreed,  and  that  is  that  the  diet  should  be  varied  and  should  be 
so  arranged  as  to  allow  of  substitution  of  various  articles,  so  that  the 
ration  may  be  varied  to  suit  the  changing  conditions.  This  varia- 
tion should  be  made  by  the  commander,  on  the  spot  where  the  army 
is  located,  and  not  by  some  one  unacquainted  with  the  exact  surround- 
ings and  needs  of  the  men.  Owing  to  the  carelessness  or  ignorance 
of  commanders,  a  monotonous,  disease-producing  fare  is  often  fur- 
nished, when  the  food  might  easily  be  varied  and  rendered  suitable. 
A  well-selected  dietary  presupposes  a  competent  commanding  officer. 

The  dryness  and  sameness  of  the  food  of  soldiers  doubtless  are  re- 
sponsible for  much  of  the  drunkenness  that  occurs  among  them. 

When  the  troops  are  in  permanent  camp,  within  reach  of  markets, 
and  when  the  facilities  for  cooking  have  been  properly  arranged, 
practically  the  same  ration  as  is  supplied  in  the  g*arrison  may  be 
used.  When  at  a  distance  from  the  base  of  supplies  and  with  no 
available  market,  the  food  must  be  of  such  a  nature  as  to  allow  it 
to  be  easily  transported  in  the  supply  wagons.  When  on  the  march, 
the  diet  is  essentially  the  same  as  when  at  a  distance  from  the  base 
of  supplies.  If  possible,  food  may  be  purchased  on  the  way  from 
the  company's  fund,  but  if  the  march  is  through  a  wilderness,  either 
pork  or  bacon  must  be  used.  On  account  of  its  ease  of  preparation, 
bacon  is  usually  chosen.  Captain  Spurgin,  quoted  by  Woodruff, 
gives  the  following  method  of  using  pork  on  the  march,  a  method 
whose  practicability  was  tested  by  him  in  the  Indian  campaign,  when 
he  followed  the  enemy  for  hundreds  of  miles:  "As  soon  as  camp 
was  made,  a  fire  was  started  and  the  pork  was  thoroughly  boiled. 
This  was  put  away  to  cool  and  was  used  the  next  day.  At  the  same 
time  some  soup  stock  which  was  carried  along  was  made  into  soup 
for  dinner.  Whenever  it  was  convenient  and  bones  could  be  secured, 
enough  soup  stock  was  made  by  prolonged  boiling  to  last  several 
days.  Beans  were  prepared  by  cooking  them  overnight."  Hard 
bread  and  coffee  are  also  used,  and  prepared  chocolate  and  dried 

46 


(22 


ARMY  AXD  NAVY  RATION  IS 


fruit  have  likewise  been  recommended.  Experiments  have  been  made 
with  various  materials  for  emergency  rations,  among  them  being 
dried  meat  of  various  kinds,  and  grain  mixtures  that  could  be  eaten 
with  or  without  cooking. 

Various  prepared  foods  are  also  used.  In  the  German  Army 
•'Erbwurst"  is  highly  esteemed.  This  is  a  mixture  of  peameal,  fat, 
bacon,  herbs,  onions,  etc.,  put  up  in  the  form  of  small  sausages.  It 
is  manufactured  in  the  Government  factories,  the  secret  for  making 

Composition  of  Certain  Prepared  Military  Foods. 


Erbwurst 

Erbwurst  as  first  used    .... 

Erbwurst  (1887) 

Dried  pea  soup  (1) 

Dried  pea  soup  ^2) 

Kopf  s  pea  soup  (used  by  the ) 
English  army) / 


Authority. 


Blythe. 
Parkes. 

Konig. 

fS.  P.  Sharpless, 
1     Boston. 


it  having  been  purchased  by  the  German  Government  from  the  in- 
ventor for  $25,000.  If  used  too  continuously,  it  is  liable  to  produce 
flatulence  and  diarrhea,  and  a  strong  dislike  for  it  is  engendered. 
Its  chief  value  lies  in  the  fact  that  it  is  lighter  and  more  easily 
transported  than  most  any  other  form  of  food,  and  that  it  is  easily 
prepared  for  us«.  English  soldiers  object  to  it  on  account  of  its. 
seasoning,  but  employ  similar  preparations  of  pea  soup. 

Comparison  of  Foods  of  Soldiers  with  Various  Other  Dietaries. 


German  soldier  (peace  footing) 

Fully  fed  tailors,  England 

Travel  ration,  U.  S.  A 

Machinist  (Connecticut) 

Factory  operatives  (Massachusetts) 

Factory  operatives  (French  Canadians,  Mass.) 

German  war  ration  (extraordinary)     

U.  S.  garrison  ration  (including  canteen)   .   .   . 

Same  (including  beer) 

V.  S.  field  ration  (average) 

Machinist  (Massachusetts)     

Teamsters,  hard  work  (Massachusetts)    .  .  .   . 


Grams. 


114 
131 
135 
105 
114 
118 
157 
152 
155 
85 
182 
254 


39 
39 
132 
147 
150 
204 
285 
180 
180 
280 
254 
363 


480 
525 
400 
399 
522 
549 
331 
570 
633 
500 
617 
826 


2800 
3055 
3400 
»435 
4000 
4630 
4650 
4621 
4907 
5000 
5640 
7805 


Grains. 


277 
318 
328 
255 
277 
287 
382 
370 
377 
206 
442 
617 


4443 

4862 
5194 
5145 
6(V18 
6901 
6750 
6806 
7446 
7247 
8423 
9950 


In  addition  to  the  foregoing,  either  tea  or  coffee  must  be  supplied. 
It  must  be  borne  in  mind  that  the  emergency  rations  are  to  be  used 
only  when  necessary,  and  that  they  are  not  to  be  relied  upon  for  any 
length  of  time.  They  may  contain  the  proper  proportions  of  pro- 
tein, etc.,  but  they  are  dried  foods,  and  their  bulk  is  too  small.     It 


AUAIY  KATIOMS 


723 


is  impossible  to  compress  sufficient  food  into  a  small  compass,  and 
consequently  condensed  foods  of  any  kind  are  of  little  value. 

At  the  present  day,  the  preservation  of  food  has  reached  a  degree 
of  perfection  when  almost  ever}'  variety  of  food  can  be  preserved 
for  use.  Where  transportation  facilities  permit,  these  may  be  used, 
but  they  are  bulky  and  do  not  withstand  the  extremes  of  climate  nor 
roug'h  liandling. 

RATIONS  OF  FOREIGN  ARMIES 

The'  student  is  referred  to  the  article  by  Major  Woodruff  in  the 
^Medical  Record,  May,  1899,  page  701,  from  which  the  accompanying 
table  is  taken. 


17i£  United  i&ates  and  Foreign  Army  Rations  Compared.— 

-( Woodruff.) 

Nation. 

Ration. 

m 

a 

m 

_a) 

Remarks. 

f 

c 
"3 

CLh 

t^ 

o 

t> 

Gm. 

Gm. 

Gm. 

1.  England  .  .  . 

.  1.  Home 

2.  Foreign  station  or  under  can- 

93 

61 

244 

1938 

Ino.1. 

vas  at  home 

111 

80 

244 

2175 

3.  March 

120 

80 

327 

2550 

J 

4   War                        \  Maximum 
^  "'^ 1  Minimum 

165 

128 

425 

3634 

1 

133 

92 

425 

3204 

VNo.  2. 

Sometimes  2  ounces  of  rum 

175 

j 

2.  Spain    .... 

1    PPftpp                    \  Maximum 
•  *•  ^^*^® \  Minimum 

147 
120 

87 
62 

588 
500 

3729 
3421 

1  No.  3. 

2.  War,  on  march  \  Maximum 

131 

94 

522 

3327 

) 

or  in  the  tield     (Minimum 

113 

55 

485 

2550 

^No.  4. 

Sometimes  1.7  oz.  brandy    . 

150 

j 

3.  Austria    .  .   . 

.  1.  Peace 

155 

125 

504 

3865 

1  No.  5. 

2.  War 

165 

130 

504 

3952 

■i.  Italy 

.  1.  Garrison 

111 

130 

600 

4129 

1 

2.  Camp 

115 

133 

600 

4103 

j-  No.  6. 

3.  Marching 

125 

143 

600 

4307 

Usually  wine  added  "   •  .   . 

250 

J 

5.  Oennanj    .  . 

.  1.  Small       rations] 

and      portions  [Maximum 

150 

40 

703 

3947 

}  No.  7. 

in  garrison  and  f  Minimum 

99 

40 

502 

2827 

cantonments  .  J 

2.  Large       rations] 

and     portions  [Maximum 

172 

62 

915 

4961 

on  march  or  in    Minimum 

138 

57 

(i44 

3744 

manceuvers.  . 

3   Field                      (Maximum 

195 

151 

703 

4786 

[Minimum 

78 

75 

515 

3413 

Commanding  general  may 

add  3i  ounces  of  whisky  . 

268 

&  United  States 

1    Rvlflw                    (Maximum 
•  ^-  ^y  ^^"■^ i  Minimum 

183 
105 

260 
103 

621 
500 

5368 
3712 

2.  Usually  in  field  (Maximum 

106 

320 

540 

5166 

[no.  a 

(by  law)    .   .   .    (Minimum 

64 

240 

460 

4722 

85 

280 

500 

5000 

3.  Food  actually  eaten  in  cold 

climate,  moderate  work,  in- 

cluding all  extras  from  gar- 

den and  purchases 

155 

180 

597 

4907 

7.  France.  .  .  . 

™__                            /Maximum 

•  "" 1  Minimum 

Add  2^  ounces  of  brandy  . 

183 
146 

300 
127 

690 
520 

5455 

4015 

184 

I  No.  9. 

8.  Russia.  .  .  . 

1    PpnrP                       (Maximum 

•  *•  ^^**=® 1  Minimum 

Add  3  ounces  of  wine    .   .   . 

233 
165 

114 
65 

976 
746 

5884 

4450 

223 

Ino.IO. 

o   War                        /Maximum 
2-  ^^^ 1  Minimum 

174 

62 

805 

4583 

) 

149 

50 

640 

3.307  1  J^No.  U. 

Add  4i  ounces  of  wine  .  .  . 

362 

) 

724  ARMY  AND  NAVY  RATION  IS 

There  are  so  many  factors  to  be  taken  into  consideration  that  it 
will  be  impossible  to  analyze  here  the  rations  supplied  the  different 
armies.  Americans,  on  account  of  the  higher  plane  of  activity  on 
which  they  live,  require  the  stimulating  effects  of  an  abundance  of 
fresh  meat.  In  Europe  fresh  meat  is  expensive,  and  for  this  reason 
the  nitrogen  is  largely  supplied  in  the  form  of  peas,  beans,  cheese, 
etc.  In  the  Russian  ration  the  percentage  of  meat  is  somewhat  low, 
but  the  deficiency  is  made  up  by  bread. 

As  stated  elsewhere,  the  United  States  is  the  only  govei:nment 
that  furnishes  the  entire  ration.  Other  nations  supply  part  in  food, 
the  remainder  being  purchased  by  the  soldier  out  of  his  pay  or  out 
of  an  allowance  made  him.  These  methods  are  suitable  in  thickly 
populated  countries,  but  cannot  be  employed  for  soldiers  on  the 
frontier.  Foreign  soldiers,  especially  Germans,  receive  boxes  from 
home  to  piece  out  the  ration,  and  the  purchasing  power  of  money  for 
extras  is  greater  in  Europe  than  on  our  frontier.  The  Austrian  ra- 
tion, which  is  greatly  increased  for  field  duty,  is  said  to  be  the  most 
liberal  in  the  world.  The  Italian  ration,  considering  the  climate, 
is  liberal,  but  may  be  regarded  as  somewhat  deficient  in  nitrogen. 
The  Spanish  ration  is  said  to  supply  a  greater  variety  than  any 
other. 

In  Russia  and  France  the  rations  are  considered  liberal.  Wine 
is  issued  in  the  war  rations  of  the  principal  European  armies,  and  in 
France  this  may  be  replaced  by  an  allowance  of  cognac.  The  Amer- 
ican soldier  formerly  could  buy  reasonable  quantities  of  beer  at  the 
army  canteen; 

REMARKS 

No.  1 :  This  is  starvation  diet,  and  the  extra  food  needed  for  health 
is  purchased  and  charged  against  the  solider  (about  six  cents  a  day), 
increasing,  perhaps  doubling,  the  food  value. 

No.  2 :  Can  be  greatly  changed  to  suit  climate. 

No.  3 :  Sufficient  for  such  a  mild  climate  and  very  moderate  work. 

No.  4:  Varies  enormously  according  to  class  of  rations  issued. 
Very  many  extra  allowances  of  money  for  food. 

No.  5 :  This  is  augmented  by  four  cents  a  day  for  vegetables,  etc. 
On  the  march  a  limited  emergency  ration  is  used.  The  war  ration 
is  so  insufficient  that  commanders  of  armies  or  smaller  forces  may 
change,  supplement,  or  even  double  it. 

No.  6 :  Allowances  of  one-fifth  of  a  cent  a  day  for  condiments ; 
occasional  extra  money  allowances  for  food.  Excepting  the  protein, 
it  is  a  very  liberal  diet  for  so  mild  a  country. 

No.  7:  This  is  what  the  government  may  supply.  Usually  the 
soldier  feeds  himself  and  is  given  seven  cents  a  day  or  more  to 
reimburse  him  for  the  outlay.  The  food  eaten  is  more  than  this 
deficient  diet  allows. 


NAVY  RATIONS  725 

No.  8:  Maxima  due  to  fats  if  all  the  bacon  is  used  and  no  meat. 
The  entire  ration  is  supplied  and  intended  to  be  eaten. 

No.  9 :  Peace  ration  not  stated.  It  is  purchased  as  needed  and 
charged  against  the  soldier.  "War  ration  is  subject  to  great  augmenta- 
tion for  increased  work  or  cold  climate.  The  commanding  officer  may 
augment  ration  on  the  march. 

No.  10 :  Also  allowed  monej-  to  buy  one-half  to  one  and  one-half 
ounces  extra  meat,  and  one  to  one  and  one-half  cents  for  vegetables, 
salt,  butter,  lard,  and  groceries. 

No.  11 :  Extra  meat  and  spirits  may  be  ordered  by  the  commander- 
in-chief. 

NAVY  RATIONS 

It  was  a  notorious  fact  that  in  former  days  the  monotonous  and. 
"dead"  character  of  the  food  on  board  ship  led  to  nutrition  disorders, 
especially  scurvy,  and  in  recent  times  hard  tack  and  salt  meat  have 
been  utilized  to  a  large  extent.  Never  before  in  the  history  of  the 
navy  has  as  much  attention  been  paid  to  the  selection,  preparation, 
and  serving  of  food.  In  place  of  the  poorly  prepared,  monotonous 
diet  of  former  days  the  sailor  is  served  with  the  following  ration : 

"Naval  Act,  June  29,  1906. — Provided,  That  sections  fifteen  hun- 
dred and  eighty  and  fifteen  hundred  and  eighty-one,  Revised  Statutes, 
be  amended  to  read  as  follows: 

"Sec.  1580. — The  Navy  ration  shall  consist  of  the  following  daily 
allowance  of  provisions  to  each  person :  One  pound  and  a  quarter 
of  salt  or  smoked  meat,  with  three  ounces  of  dried  or  six  ounces  of 
canned  or  preserved  fruit,  and  three  gills  of  beans  or  pease,  or  twelve 
ounces  of  flour;  or  one  pound  of  preserved  meat,  with  three  ounces 
of  dried  or  six  ounces  of  canned  or  preserved  fruit  and  eight  ounces 
of  rice  or  twelve  ounces  of  canned  vegetables,  or  six  ounces  of  desic- 
cated vegetables ;  together  with  one  pound  of  biscuit,  two  ounces  of 
butter,  four  ounces  of  sugar,  two  ounces  of  coft'ee  or  cocoa,  or  one- 
half  ounce  of  tea  and  one  ounce  of  condensed  milk  or  evaporated 
cream;  and  a  weekly  allowance  of  one-quarter  pound  of  macaroni, 
four  ounces  of  cheese,  four  ounces  of  tomatoes,  one-half  pint  of 
vinegar  or  sauce,  one-quarter  pint  of  pickles,  one-quarter  pint  of 
molasses,  four  ounces  of  salt,  one-half  ounce  of  pepper,  one-eighth 
ounce  of  spices,  and  one-half  ounce  of  dry  mustard.  Seven  pounds 
of  lard,  or  a  suitable  substitute,  shall  be  allowed  for  every  hundred 
pounds  of  flour  issued  as  bread,  and  such  quantities  of  yeast  and 
flavoring  extracts  as  may  be  necessary. 

"Sec.  1581. — The  following  substitution  for  the  components  of  the 
ration  may  be  made  when  deemed  necessary  by  the  senior  offlcer  pres- 
ent in  command :  '  For  one  and  one-quarter  pounds  of  salt  or  smoked 
meat  or  one  pound  of  preserved  meat,  one  and  three-quarter  pounds 
of  fresh  meat  or  fresh  fish,  or  eight  eggs;  in  lieu  of  the  articles  usu- 


726  ARMY  AND  NAVY  KATlOMi 

ally  issued  with  salt,  smoked  or  preserved  meat,  one  and  three- 
quarter  pounds  of  fresh  vegetables;  for  one  pound  of  biscuit,  one 
and  one-quarter  pounds  of  soft  bread  or  eighteen  ounces  of  flour; 
for  three  gills  of  beans  or  pease,  twelve  ounces  of  flour  or  eight 
ounces  of  rice  or  other  starch  food,  or  twelve  ounces  of  canned 
vegetables ;  for  one  pound  of  condensed  milk  or  evaporated  cream,  one 
quart  of  fresh  milk ;  for  three  ounces  of  dried  or  six  ounces  of  canned 
or  preserved  fruit,  nine  ounces  of  fresh  fruit ;  and  for  twelve  ounces 
of  flour  or  eight  ounces  of  rice  or  other  starch  food,  or  twelve  ounces 
of  canned  vegetables,  three  gills  of  beans  or  pease;  in  lieu  of  the 
weekly  allowance  of  one-quarter  pound  of  macaroni,  four  ounces  of 
cheese,  one-half  pint  of  vinegar  or  sauce,  one-quarter  pint  of  pickles, 
one-quarter  pint  of  molasses,  and  one-eighth  ounce  of  spices,  three 
pounds  of  sugar,  or  one  and  a  half  pounds  of  condensed  milk,  or  one 
pound  of  coft'ee,  or  one  and  a  half  pounds  of  canned  fruit,  or  four 
pounds  of  fresh  vegetables,  or  four  pounds  of  flour. 

"  'An  extra  allowance  of  one  ounce  of  coffee  or  cocoa,  two  ounces 
of  sugar,  four  ounces  of  hard  bread  or  its  equivalent,  and  four  ounces 
of  preserved  meat  or  its  equivalent  shall  be  allowed  to  enlisted  men 
of  the  engineer  and  dynamo  force  who  stand  night  watches  between 
eight  o'clock  postmeridian  and  eight  o'clock  antemeridian,  under 
steam.'  " 

"Naval  Act,  March  2,  1907. — An,y  article  comprised  in  the  navy 
ration  may  be  issued  in  excess  of  the  authorized  quantitj^  provided 
there  be  an  underissue  of  the  same  value  in  some  other  article  or 
articles. ' ' 

The  above  ration  is  not  so  much  an  expression  of  what  the  sailor 
should  have,  as  what  he  wants. 

As  Gatewood  aptly  remarks,  "Contentment  in  naval  service  in 
relation  to  food  and  water  makes  for  good  discipline,  and  content- 
ment without  work  is  impossible.  .  .  .  Contentment  facilitates  vol- 
untary enlistment,  and  a  service  that  supplied  protein  food  in  amounts 
exactly  to  meet  the  requirements  of  the  body  as  evolved  from  the 
mathematics  of  nitrogenous  equilibrium  would  not  secure  content- 
ment. That  is  the  basis  of  the  daily  amounts  of  food  in  the  navy 
ration,  the  amounts  depending  essentially  not  upon  what  it  is  thought 
men  ought  to  eat,  but  upon  what  experience  has  demonstrated  they 
desire  to  eat." 

The  navy  ration  must  be  viewed  from  the  very  practical  point  of 
giving  efficient  service,  and  it  should  be  sufficiently  elastic  to  vary 
with  the  tastes  of  the  men  and  to  life  under  the  varying  conditions 
under  which  the  sailor  lives.  The  diet  in  the  tropics  will  differ  from 
that  in  the  cooler  regions  just  as  the  appetite  and  metabolism  vary 
with  the  changing  temperature,  degrees  of  light,  and  humidity.  It 
is  not  very  well  understood  at  present,  but  it  is  quite  probable  that 


NAVY  h\[TI0\8 


727 


the  surface  nerves  react  to  external  influences,  and  thus  affect  the 
metabolism  to  a  great  extent. 

Selection  of  food  is  of  great  importance,  and  much  can  be  done 
by  having  a  variety  of  different  perserved  and  canned  meats,  fruits, 
and  vegetables. 

The  nutritive  value  of  navy  rations  is  difficult  to  compare,  as  it 
must  take  into  account  whether  it  refers  to  the  entire  ration  as  issued 
or  as  it  is  consumed,  or  as  it  may  be  modified  by  way  of  commutation. 
Exact  information  is  difficult  to  obtain,  but  a  comparison  of  our  ra- 
tion with  that  of  other  nations  has  been  made  as  correctly  as  possible, 
with  the  limitations  indicated  by  Surgeon  J.  D.  Gatewood,  to  whom  I 
am  indebted  for  the  following  table : 


Eaten. 

Digestible. 

<6 

3 

"3 

> 

a 

3 
u 

Naval  Dietaries. 

d 

'33 

2 

1 

t 

-a 

o 

■£ 

O 

d" 
1 

1 

a 

6 

•f-« 

'C 

d 

1.  U.  S.  Navy  (sea  ration) 

2.  U.  S.  Navy  (fresh  provisions)   .   . 

3.  U.  S.  Navy  (usual) 

4.  U.  S.  Navy  (engineer  force)  .  .  . 

5.  Japanese  Navy  (average)    .... 

6.  French  Navy  "(average) 

7.  French  Navy  (engineer  force)  .  . 

8.  British  Navy  (average) 

9.  British  Navy  (engineer  force)  .   . 

Gm. 

138 
145 
142 
182 

126 
170 
184 
127 
175 

Gm. 

269 
135 
192 
218 

56 
34 
35 
110 
149 

Gm. 

556 
444 
492 
624 

607 
524 
608 
601 
728 

Gm. 

127 
134 
131 
168 

116 
156 
169 
117 
161 

Gm. 

256 
129 
183 

207 

53 
32 
33 

104 
141 

Gm. 

540 
431 
478 
606 

589 
508 
590 
583 
706 

Cals. 

5180 
3563 
4256 
5174 

3430 
3078 
3407 
3891 
4938 

1 

8.7 
5.3 
6.7 
6.3 

6.1 
3.7 
3.9 
7.2 
6.6 

The  figures  in  the  above  table  relating  to  the  French  Navy  should 
be  accepted  with  not  a  little  reservation,  as  in  the  data  obtainable 
it  is  not  clear  that  all  necessary  factors  have  been  included  or  that 
any  allowance  for  waste  is  made.  It  is  probable  that  the  ration  is 
given  as  issued  and  not  as  consumed.  In  regard  to  the  Japanese 
Navy,  it  may  be  noted  that  the  average  weight  of  the  enlisted  men 
seems  to  be  about  129  pounds. 

It  may  be  considered  that  the  average  man  in  the  United  States 
Navy  consumes  dailj^  142  grams  of  protein,  193  grams  of  fat,  and 
492  grams  of  carbohydrates  with  a  fuel  value  of  4256  calories.  The 
engineer  forces  are  given  an  additional  ration  as  issued  of  42  grams 
of  protein,  27  of  fat,  and  139  of  carbohydrate,  which  makes  the 
engineer  force  receive  more  protein  than  is  given  in  Atwater  's  Stand- 
ards for  a  man  at  very  hard  muscular  labor. 

The  navy  ration  must  be  studied  from  several  points  of  view,  viz., 
its  acceptability  to  the  people  who  are  to  consume  it,  and  this,  per- 
haps, for  reasons  stated  above,  comes  first;  its  availability  and  its 


728  ARMY  AyD  yAVY  HATlOyS 

keeping  qualities  and  its  storage,  besides  the  all-important  question 
of  securing  the  proper  amount  of  nutriment  within  a  fixed  daily  cost 
per  person.  All  of  these  and  other  questions  are  considered  in  an 
excellent  article  by  J.  D.  Gatewood  in  his  work  on  Naval  Hygiene,  to 
which  the  reader  desiring  more  extended  information  is  referred. 

The  following  regulations,  taken  from  the  General  ^Mess  ^Manual 
and  Cook  Book  for  Use  on  Board  Vessels  of  the  United  States  Navy, 
1902,  gives  many  interesting  facts  concerning  the  organization  and 
management  of  the  mess : 

PART  I.— THE  GENERAL  MESS 

Organization  and  Administration. — 1.  The  general  messing  system  is,  by  the 
regulations,  obligatory  on  board  of  all  vessels  of  the  navy.  The  mess  must  include 
all  enlisted  men  of  the  navy  and  marine  corps,  excepting  chief  petty  officers  and 
officers'  servants,  and  its  members  are  to  be  divided  into  messes  of  about  twenty 
men  each,  and  as  nearly  as  possible  messed  by  divisions  instead  of  by  ratings,  as 
has  heretofore  been  the  custom.  By  this  method  the  petty  officers  will  be  scat- 
tered among  the  messes  and  there  can  be  no  complaint  on  account  of  discrimina- 
tion— all  faring  alike. 

2.  A  messman  is  to  be  detailed  for  each  mess,  and  he  is  to  receive  the  food  from 
the  cooks  at  the  galley,  serve  it  at  the  mess  table,  and  is  responsible  for  the  care 
and  the  cleanliness  of  the  mess  gear  and  mess  tables. 

3.  The  chief  commissary  steward,  or  commissary  steward,  the  cooks  and  bakers, 
together  with  the  storekeeper  (when  a  store  is  established  on  the  ship),  form  the 
enlisted  force  of  the  commissary  department.  They  are  the  assistants  of  the  pay 
officer  and  belong  to  the  pay  division. 

4.  The  responsibility  of  the  commissary  and  his  assistant  ceases  with  the  deliv- 
ery of  the  food  to  the  messmen  at  the  galley. 

5.  The  established  rate  of  pay  being  sufficient  to  secure  the  services  of  competent 
and  experienced  men,  the  payment  of  any  gratuity,  either  by  the  commissary  or 
by  the  men  themselves,  to  any  person  employed  in  the  service  of  the  general  mess 
is  forbidden  by  the  regulations. 

6.  The  commanding  officer  should  see  that  proper  facilities,  including  such  boats 
and  men  as  may  be  necessary,  are  afforded  the  commissary  for  getting  mess  stores 
on  board  and  stowing  them. 

7.  It  should  be  thoroughly  understood  that  the  general  mess  is  not  an  organiza- 
tion managed  by  its  members,  as  was  the  "berth-deck  mess." 

8.  In  addition  to  the  pay  provided  for  enlisted  men,  the  Government  undertakes 
to  subsist  them,  and  tliis  it  does  at  whatever  expense  may  be  necessary.  The  fixed 
value  of  commutation  for  one  ration  is,  by  law,  30  cents,  but  the  commutation  of 
rations  is  a  privilege,  not  a  right,  and  the  idea  prevalent  among  enlisted  men 
that  they  are  entitled  to  receive  just  30  cents'  worth  of  food  each  day,  or  30  cents 
in  money,  is  erroneous. 

9.  Under  the  general  messing  system  the  Government  subsists  the  men  entirely, 
and  they  have  no  more  voice  in  the  management  of  the  commissary  department 
than  in  any  other  department  of  the  ship.  The  Government,  through  its  author- 
ized officer,  provides. them  with  the  ration  allowed  by  law.  The  food  is  purchased, 
cooked,  and  served  entirely  at  the  Government  expense,  and  its  value,  whether  it 
be  more  or  less  tlian  30  cents  per  diem  per  man,  is  a  matter  with  which  the  men 
themselves  have  nothing  to  do. 

10.  In  case  any  man  considers  that  he  is  improperly  subsisted  he  has  the  right, 
which  all  persons  in  the  navy  have,  to  state  his  grievance  at  the  proper  time  and 
place  to  his  commanding  officer,  who  should  then  cause  the  commissary  to  investi- 
gate the  matter,  and,  if  the  complaint  is  well  founded,  to  take  steps  to  place  the 
responsibility  and  to  prevent  a  recurrence  of  the  fault  complained  of. 

11.  The  men  are  entitled  to  the  full  benefit  of  the  money  and  stores  allowed  for 
their  subsistence,  and  no  expenditure  can  be  made  from  the  general  mess  fund 
except  for  the  benefit  of  the  mess;  nor  can  any  of  this  money,  or  these  stores,  be 
withheld   (when  they  can  be  used  to  advantage)   and  allowed  to  accumulate  as  a 


NAVY  HATIOSS  729 

surplus.  In  cases,  however,  where  a  surplus  of  either  money  or  stores  does  un- 
avoidably exist  when  a  ship  is  placed  out  of  commission,  the  members  of  the  moss 
have  no  claim  whatever  to  any  part  of  it,  and  it  reverts  to  tlie  (Government,  tlie 
stores  beintr  taken  up  as  a  gain  on  issues  and  tiie  money  being  credited  to  the 
appropriation  "Provisions,  Navy." 

12.  Subsistence  of  enlisted  men  absent  from  the  ship  on  duty  will,  when  prac- 
ticable, be  furnislied  by  the  general  mess.  When  men  are  landed  in  large  numbers 
for  an  expedition  or  for  going  into  camp  with  the  expectation  of  l)eing  absent 
from  the  ship  for  more  tlian  twenty-four  iiours,  the  commissary  or  the  commissary 
steward,  according  to  the  proportion  of  the  ship's  comijany  landed  and  the  impor- 
tance of  the  expedition,  together  with  such  cooks  and  bakers  as  may  be  necessary, 
and  a  suthcient  number  of  messmen,  should  constitute  tlie  commissary  corps. 

The  Commissary. — 13.  The  pay  officer  of  the  ship,  or,  in  ships  having  no  pay 
officer,  an  officer  designated  by  the  captain,  is  tlie  commissary,  and  is  solely  re- 
sponsible for  the  purchase  and  preparation  of  the  food  for  the  general  mess,  the 
care  of  the  stores,  and  the  judicious  expenditure  of  mess  funds,  keeping  the  ac- 
counts of  the  mess  and  administering  all  its  aJlairs  except  the  serving  of  the  food 
at  the  mess  table. 

14.  His  authority  in  the  performance  of  these  duties  is  commensurate  with  liis 
responsibility,  and  all  persons  employed  in  the  service  of  the  general  mess  are 
subject  to  his  orders. 

15.  The  commissary  should  frequently  inspect  the  storerooms  allotted  to  the 
general  mess,  and  see  that  the  stores  are  properly  stowed  and  that  the  rooms  are 
dry  and  well  ventilated.  Any  deterioration  in  the  stores  being  a  direct  loss  to 
the  mess,  great  care  should  be  exercised  in  their  selection,  and  no  greater  quantity 
should  be  bought  at  one  time  than  can  be  used  within  the  period  they  may  be 
expected  to  keep  in  good  condition. 

16.  The  commissary  should  not  permit  any  stores  to  be  purchased  until  a  list 
of  them  has  been  submitted  to  him  and  carefully  examined  and  approved.  No 
stores  should  be  received  on  board  unless  accompanied  by  a  bill  or  memorandum 
by  which  they  can  be  checked  oft';  and  before  being  stowed  away  all  stores  should 
be  carefully  inspected  by  the  commissary  or  the  commissary  steward.  No  bills 
should  be  contracted  that  cannot  be  paid  from  the  funds  in  hand  or  by  the 
ration  money  that  will  accrue  to  the  mess  during  the  current  month.  All  bills 
should  be  settled  at  the  end  of  each  month,  and  always  before  the  ship  sails  from 
port. 

17.  The  commissary  should  keep  the  cash  accounts  of  the  mess  so  that  they  can 
be  conveniently  audited  by  the  general  inspector  of  the  pay  corps,  the  paymaster 
of  the  fleet,  or  by  the  board  appointed  for  the  purpoi^e.  All  expenditures  must 
be  substantiated  by  vouchers,  which  are  to  be  exhibited  when  the  accounts  are 
inspected. 

18.  He  should  cause  the  commissary  steward  to  keep  a  stock  account  which 
should  embrace  all  stores  and  all  property  of  the  general  mess.  The  value  of 
the  balance  shown  upon  this  stock  accoiuit  should  be  taken  into  consideration  in 
making  up  the  statement  of  the  financial  condition  of  the  mess. 

19.  The  commissary  should,  when  he  deems  it  advisable,  submit  written  reports 
and  recommendations  to  the  captain  regarding  tlie  general  mess,  and  he  must  do 
so  whenever  the  interests  of  the  mess  require  any  change  which  he  himself  is  not 
authorized  to  make. 

20.  The  commissary  should  mark  the  enlisted  men  of  his  department  in  pro- 
ficiency in  rating  and  should  immediately  report  any  inefficiency  or  carelessness 
in  their  performance  of  duty. 

21.  He  should  frequently  inspect  the  food  before  it  is  delivered  to  the  messmen 
at  the  galley,  and  in  case  he  finds  it  improperly  prepared,  should  take  steps  to 
prevent  any  further  occurrence  of  the  kind.  If  cooks  are  not  thoroughly  com- 
petent, they  should  be  made  to  follow  strictly  the  recipes  in  this  book,  and 
flagrant  cases  of  incompetency  should  be  reported. 

The  Commissary  Stewards. — 22.  The  chief  commissary  steward  or  commissary 
steward  is  the  chief  petty  officer  in  charge,  under  the  commissary,  of  the  general 
mess.  He  is  entitled  to  respect  and  obedience  from  all  persons  of  inferior  rating 
while  in  the  performance  of  his  duties,  and  he  is  responsible  for  the  proper  execu- 
tion of  the  orders  of  the  commissary.  The  daily  bill-of-fare  should  be  made  out 
by  the  commissary  steward  and  submitted  to  the  commissary,  and  the  necessary 


730  ARMY  AND  NAVY  KATWMi 

stores  issued  to  the  cooks  at  the  galley.  He  should  direct  the  manner  of  its 
preparation  and  shall  be  in  charge  of  the  galley  and  the  men  employed  at  it,  and 
should  frequently  inspect  the  food  before  it  is  delivered  to  the  messmen  to  be 
served.  He  should  see  that  the  galley  and  all  the  galley  utensils  are  kept  in 
proper  condition,  giving  particular  attention  to  their  cleanliness. 

23.  He  should  report  to  the  commissary  daily,  in  writing,  all  purchases  made 
and  debts  contracted,  and  keep  that  officer  advised  of  the  needs  of  the  mess.  He 
is  to  draw  from  the  pay  department,  at  the  appointed  times,  such  Government 
stores  as  are  due  the  mess,  and  must  keep  an  account  of  these  stores  for  the  veri- 
fication of  tlie  provisions  return  at  the  end  of  each  quarter.  When  fresh  provi- 
sions are  issued,  he  should  be  on  deck,  when  practicable,  to  receive  them  from 
the  representative  of  the  pay  department  as  soon  as  they  have  been  received  on 
board  and  inspected.  In  case  tliese  fresh  provisions,  or  any  other  stores  issued 
to  tlie  mess  by  the  pay  department,  are,  in  the  opinion  of  the  commissary  steward, 
of  inferior  quality  and  unfit  for  issue  he  should  report  the  matter  to  the  commis- 
sary, wlio  shall  make  a  personal  investigation,  and,  in  case  he  finds  the  objection 
well  founded,  should  take  the  necessary  steps  to  provide  other  stores,  as  pre- 
scribed by  the  regulations.  An  issuing  "book  should  be  kept  by  the  pay  yeoman 
and  signed  daily  by  the  commissary  steward,  in  order  that  no  question  may 
arise  at  tlie  end  of  the  quarter  as  to  the  stores  drawn  by  the  general  mess.  The 
commissary  steward  may,  with  the  autliority  of  the  commissary,  draw  from  the 
pay  department  such  Government  stores  as  are  required  in  excess  of  the  allow- 
ance, and  these  stores  shall  be  paid  for  from  the  mess  fund  at  the  end  of  each 
montli. 

The  Cooks. — 24.  The  senior  cook,  or,  if  there  are  two  or  more  of  the  same  rat- 
ing, one  selected  by  the  commissary,  should  be  in  immediate  cliarge  of  tlie  galley 
and  act  in  the  capacity  of  head  cook.  He  should  be  held  strictly  responsible  for 
the  cleanliness  of  the  galley  and  the  utensils  pertaining  to  it,  for  the  maintenance 
of  discipline  among  his  assistants,  for  the  proper  preparation  of  the  food,  and 
for  having  the  meals  ready  at  the  prescribed  hours.  He  should  personally  super- 
intend the  cooking  of  all  meals,  and  should  carefully  inspect  all  food  before  it  is 
delivered  to  the  messmen.  It  is  his  duty  to  report  to  the  commissary  any  in- 
efficiency or  neglect  on  the  part  of  his  assistants;  otherwise  the  entire  blame  for 
poor  cooking  or  any  other  delinquency  at  the  galley  should  rest  upon  him.  The 
head  cook  should  keep  the  commissary  steward  informed  as  to  the  requirements 
of  the  galley,  and  should  from  time  to  time  prepare  lists  of  articles  required  by 
him  in  his  cooking,  which  are  not  included  in  the  navy  ration.  He  is  responsible 
for  the  galley  utensils,  and  will  report  immediately  when  any  are  lost,  worn  out, 
or  damaged. 

25.  The  other  cooks  should,  as  far  as  possible,  be  assigned  specific  duties  at  the 
galley  in  order  that  the  responsibilitj'  for  any  neglect  may  readily  be  placed. 
One  should  be  detailed  as  "meat  cook,"  another  as  "vegetable  cook,"'  and  one  man 
should,  in  addition  to  other  duties,  be  held  responsible  for  the  preparation  of  the 
cofi'ec  and  tea. 

26.  The  cooks  in  the  lower  ratings  should  be  detailed  for  starting  fires,  clean- 
ing the  galley  and  utensils  (regular  cleaning  stations  being  assigned  them),  and 
for  preparing  the  food  for  cooking. 

27.  The  organization  of  the  force  at  the  galley  should  be  as  complete  and 
efficient  as  that  of  a  gun  division. 

The  Bakers. — 28.  The  commissary  steward  should  issue  to  the  baker  such 
quantities  of  flour  and  other  ingredients  as  may  be  necessary  for  making  bread 
for  the  mess  and  keep  him  advised  of  the  amount  of  bread  required  from  day  to 
day. 

29.  The  baker,  or,  in  ships  which  are  allowed  two  bakers,  the  baker  first  class, 
is  to  be  held  responsible  for  the  proper  baking  of  the  bread  and  for  its  delivery 
to  the  messmen  at  the  appointed  times.  He  is  also  responsible  for  the  condition 
of  the  bake-ovens  and  the  utensils  used  by  him. 

PART  II.— THE  COMMISSARY  STORE 

Establishment  and  Administration. — 30.  There  being  no  public  funds  avail- 
able for  the  establishment  of  a  store  on  board  ships  of  the  na\y,  such  establish- 
ment is  not  made  compulsory,  but  is  left  to  the  discretion  of  the  commanding 


NAVY  RATIOXS  731 

officer.  The  advantages  of  such  a  store  are,  however,  so  obvious  and  so  great 
that  provision  is  made  in  the  regulations  for  its  administration  in  ships  where  it 
exists  or  may  be  establislied. 

31.  The  objects  of  a  commissary  store  are: 

( 1)  To  enable  the  men  to  purcliase  a  better  quality  of  the  articles  usually 

ol)tained  from  biimboat  men,  and  at  a  lower  price. 

(2)  To  return  directly  to  tlie  men  all  profits  from  tlieir  purchases  not 

needed  for  carrying  on  the  business. 

(3)  To  bring  under  official  control  the  sale  of  all  merchandise  on  board 

ship,  and  thus  do  away  with  bumboat  men  and  peddlers,  and  re- 
duce the  chances  of  liquor  or  other  unauthorized  articles  being 
brought  on  board.  The  sale  of  any  merchandise  on  board  ship, 
except  by  the  store,  should  be  prohibited  as  far  as  practicable. 
Tailors,  persons  doing  repairing,  and  those  selling  special  articles 
which  cannot  conveniently  be  handled  by  the  store,  may  be  exempt 
from  this  prohibition,  but  dealers  in  milk.  pies,  fruit,  and  such 
articles  should  not  be  allowed  to  sell  to  the  men. 

32.  The  commissary  should  make  agreement  with  reliable  merchants  to  supply 
to  the  store,  while  tlie  ship  is  in  port,  such  stores  as  are  salable  but  can  not  be 
carried  in  stock,  and  these  articles  should  be  delivered  to  the  storekeeper  and  by 
him  sold  to  the  men  at  a  very  small  advance.  For  example,  if  it  be  thought  ad- 
visable to  have  milk  for  sale  in  the  store  when  the  ship  is  in  port,  the  commis- 
sary should  arrange  with  a  dealer  to  place  on  board,  at  a  specified  time  each  day, 
a  quantity  of  milk  at  a  fixed  price,  such  quantity  as  may  be  sold  to  be  paid  for, 
and  the  balance  to  be  taken  away  by  the  dealer. 

33.  The  stock  being  purchased  from  reliable  firms  at  wholesale  prices,  will  be 
better  in  quality  and  lower  in  price  than  that  usually  carried  by  bumboats  or 
itinerant  merchants.  The  greater  part  of  the  retail  dealer's  profit  should  revert 
directly  to  the  purchaser  at  the  time  he  buys  the  article — that  is,  the  price 
charged  should  be  very  little,  if  any,  above  the  wholesale  price.  Some  profit 
must  be  made,  however,  and  all  that  is  not  required  for  incidental  expenses  of 
the  store  must  be  turned  over  to  the  general  mess  fund,  and  thus  it,  also,  reverts 
to  the  men  in  the  form  of  delicacies  for  the  mess  table,  such  as  are  not  a  part  of 
the  navy  ration. 

34.  In  ships  where  the  men  desire  to  subscribe  for  the  original  stock  of  a  com- 
missary store,  and  the  commanding  officer  authorizes  its  establishment,  the  com- 
missary is,  by  the  regulations,  placed  in  charge  of  it.  This  officer  is  to  receive 
voluntary  subscriptions  from  the  crew,  giving  them  receipts  ( stated  to  be  not 
negotiable)  for  the  amount  subscribed,  with  the  agreement  that  these  receipts 
may  be  surrendered  and  the  amount  of  the  subscription  refunded  after  the  orig- 
inal stock  has  been  paid  for  and  tlie  business  is  on  a  good  financial  basis.  The 
original  subscribers,  after  they  liave  been  paid  the  amount  of  their  subscriptions, 
have  no  further  claim  upon,  nor  interest  in,  the  store. 

35.  During  this  period  it  is  advisable  to  make  the  prices  correspond  with  those 
of  retail  dealers  in  order  that  the  store  may  be  independent  as  soon  as  possible, 
but  when  all  indebtedness  has  been  discharged  and  the  store  is  self-supporting, 
the  profits  should  be  reduced  to  a  minimum,  it  being  always  borne  in  mind  that 
making  money  is  not  one  of  the  objects  of  the  store.  The  injustice  of  making 
profits  from  sales  to  one  set  of  men  to  be  divided  among  another  set  at  the  ex- 
piration of  a  cruise  is  manifest,  and  for  tliis  reason  the  regulations  provide  that 
such  profits  be  used  to  improve  the  bill-of-fare  of  the  general  mess,  but  with  the 
present  ample  ration  no  addition  to  the  mess  fund  should  be  necessary ;  and,  by 
reduction  in  prices  from  time  to  time,  as  experience  dictates,  the  monthly  surplus 
should  be  reduced  to  a  minimum,  thus  disposing  of  the  regular  retail  dealer's 
profit  in  the  most  equitable  manner  possible,  i.  e.,  by  giving  the  benefit  of  it  to 
each  purchaser  in  the  form  of  a  discount. 

36.  It  is  impracticable  to  operate  a  store  unless  a  suitable  room,  used  for  no 
other  purpose  and  to  which  only  the  storekeeper  has  access,  is  available  for  the 
purpose. 

37.  No  cash  will  be  received  at  the  store  for  articles  purchased,  but  sales  will 
be  made  under  the  following  system : 

Books  of  tickets  of  a  form  prescribed  by  the  Bureau  of  Supplies  and  Accounts 
will  be  issued  for  cash  by  the  pay  officer  and  storekeeper  and  will  be  negotiable 


732  'army  ASD  yAVY  KAT10:!ilS 

at  the  store  in  lieu  of  money.  The  issue  of  these  books  by  the  pay  officer  will  be 
made  at  tlie  same  time  as  the  issue  of  monthly  money,  and  by  the  storekeeper 
daily  during  the  month  as  the  men  may  desire  to  purchase  them.  For  the  latter 
issues  the  pav  officer  will  turn  over  from  time  to  time  a  limited  number  of  books 
to  the  storekeeper,  who  will  be  held  strictly  accountable  therefor,  and  will  turn 
in  to  the  pay  officer  daily  the  money  received  for  same. 

The  Commissary. — 38.  The  commissary  of  the  ship  has  charge  of  the  ship's 
store.  He  is  allowed  the  services  of  a  yeoman  for  duty  as  storekeeper.  The 
commissary  should  give  his  personal  attention  to  the  purchase  of  stock  for  the 
store,  shoiild  fix  the  prices  at  which  the  articles  are  sold,  establish  a  business- 
like system  for  the  operation  of  the  store,  and  direct  all  its  affairs.  He  should 
keep  the  cash  account  and  cause  the  commissary  steward  to  turn  in  daily  all 
money  not  required  for  making  change.  He  is  to  turn  over  to  the  general  mess 
fund,'  monthly,  so  much  of  the  surplus  of  the  store  as  is  not  required  for  the 
purchase  of  new  stock,  and  he  should  endeavor  to  so  regulate  the  prices  that  this 
surplus  will  not  be  larger  than  necessary. 

39.  All  the  accounts  of  the  commissary  store  should  be  kept  in  such  manner  as 
to  admit  of  ready  inspection  by  the  general  inspector  of  the  pay  corps,  the  pay- 
master of  the  fleet,  or  by  the  board  appointed  for  that  purpose. 

The  Storekeeper. — 40.  The  storekeeper  should  be  responsible  to  the  commis- 
sary for  the  proper  conduct  of  the  store. 

He  is  to  keep  the  account  of  the  stock,  and  of  the  sales,  and  submit  to  the 
commissary  from  time  to  time  lists  of  articles  required. 

41.  In  order  to  protect  the  store  from  any  loss,  either  through  carelessness  or 
dishonesty,  the  following  method  of  keeping  the  accounts  should  be  employed: 

At  the  end  of  each  month  an  account  of  stock  should  be  taken  by  the  commis- 
sary steward  or  the  paymaster's  yeoman,  and  the  articles  found  to  be  on  ha»d 
entered  in  a  book  similar  to  the  return  of  clothing  and  small  stores.  (This 
blank  may  conveniently  be  used  for  the  purpose,  the  headings  of  the  columns 
being  changed.)  These  quantities  represent  the  stock  on  hand  at  the  beginning 
of  the  new  month  and  to  them  should  be  added  all  stores  received  from  pur- 
chase. At  the  end  of  the  month  the  quantities  found  to  be  on  hand  should  be 
entered  in  the  proper  line  and  subtracted  from  the  total  receipts  and  the  differ- 
ence entered  as  "sales."  By  multiplying  the  number  of  each  article  sold  by  its 
selling  price  and  taking  the  total  of  that  line  in  the  return  will  be  found  the 
amount  which  the  storekeeper  should  have  received,  and  this  amount  he  should 
be  required  to  turn  in  or  account  for. 

42.  If  no  prices  are  changed  except  at  the  beginning  of  the  month,  and  if  the 
established  prices  are  displayed  on  the  store  bulletin  board  so  that  no  overcharges 
can  be  made,  this  system  will  be  a  simple  and  absolute  check  on  the  storekeeper. 

43.  The  man  selected  for  this  responsible  duty  should,  first  of  all,  be  entirely 
trustworthy.  He  must  be  quick  and  accurate  at  figures  and  write  legibly.  It  is 
his  duty  to  receive  such  stock  as  may  be  delivered  for  the  store,  conveniently 
arrange  it  in  the  storeroom,  and  keep  the  latter  clean  and  see  that  it  is  ready 
for  inspection  at  the  appointed  times.  He  is  to  open  the  store  for  the  sale  of 
merchandise  to  the  men  at  such  times  as  may  be  appointed  by  the  commissary, 
with  the  authority  of  the  captain. 

He  should  keep  a  small  memorandum  book  in  which  to  enter  the  amounts 
turned  in  daily  to  the  commissary,  and  when  that  officer  receives  the  money,  he 
should  initial  the  amount  in  the  book. 

PART  III.— THE  PREPARATION  OF  FOOD 

The  Ration. — 44.  The  dietary  of  the  enlisted  men  of  the  navy  must  necessarily 
be  based  upon  the  ration  provided  by  law.  In  general  messes,  where  the  cir- 
cumstances are  favorable,  provisions  which  are  not  a  part  of  the  ration  may  at 
times  be  purchased,  but  articles  of  which  there  is  a  supply  already  on  board  in 
the  pay  department  should  not  be  bought  unless  the  Government  stores  shall 
have  deteriorated,  in  which  case  they  should  be  surveyed  and  a  new  stock  ob- 
tained at  the  first  opportunity. 

45.  Unless  there  shoiild  be  some  good  reason  for  not  doing  so,  the  official 
issuing  table  should  be  strictly  adhered  to,  it  having  been  arranged  to  give  the 
necessary  variety. 


NAVY  RATIOXa  733 

The  Galley. — 46.  The  sliip's  oalley  (or  that  part  of  it  used  for  tlic  {General 
mess),  together  with  its  appurtenances,  is  under  the  c-luuge  of  the  commissary. 
That  officer  should  see  that  the  galley  and  its  utensils  are  properly  cared  for 
and  are  ready  for  inspection  at  the  appointed  times,  lie  should  himself  fre- 
quently inspect  this  part  of  his  department  and  advise  the  equipment  ollicer  of 
any  repairs  or  alterations  needed,  and  should,  when  occasion  demands  it,  furnish 
that  olhcer  with  a  list  of  galley  utensils  recjuiring  a  survey. 

Cooking. — 47.  On  hoard  ship,  where  the  facilities  are  necessarily  restricted 
and  the  food  lacking  in  variety  compared  to  that  obtainable  on  shore,  it  is  of  the 
highest  importance  that  the  very  best  results  possible  under  the  circumstances 
should  be  obtained.  With  a  liberal  allowance  of  cooks  and  bakers,  and  a  judi- 
cious selection  of  the  men  for  these  rates,  the  navy  ration  should  be  so  prepared 
as  to  give  the  enlisted  men  three  nourishing  and  palatable  meals  each  day,  and 
it  should  be  the  duty  of  the  commissary  department  to  see  that  this  is  done. 

Frequent  inspections  of  the  food  by  the  commissary  and  the  commissary 
steward,  and  efficiency  on  the  part  of  the  cooks,  alone  can  insure  this. 


DIETARIES  IN  PUBLIC  INSTITUTIONS 

The  diet  in  public  and  in  private  or  semiprivate  institutions,  which 
include  armies,  navies,  hospitals,  asylums,  prisons,  schools,  colleges, 
and,  in  fact,  any  place  where  numbers  of  persons  are  fed  under  the 
direction  of  a  steward,  is  a  subject  that  requires  close  attention. 
During  the  past  few  years  many  dietary  studies  have  been  made,  the 
greatest  advantage  following  where  the  results  of  such  studies  have 
been  applied.  In  the  line  of  investigation  much  still  remains  to  be 
done,  however,  for  the  public  has  not  yet  learned  the  importance  of 
applying  scientific  methods  to  the  supply  and  culinary  departments 
of  its  institutions. 

In  applying  modern  methods  to  institutions  a  number  of  principles 
must  be  considered.  These  may  best  be  understood  from  a  careful 
review  of  Dunlop's  Prison  Dietaries,  as  given  below,  from  which  it 
will  be  seen  that  the  amount  of  food  necessary  to  nourish  the  body 
is  taken  as  the  starting-point.  This  amount  is  to  be  modified  accord- 
ing to  the  condition  of  the  individuals  to  be  fed.  Age,  sex,  occupa- 
tion, environment,  physical  condition,  and  the  like  must  all  be  taken 
into  account.  The  evaporation  and  waste  in  food  kept  and  used  must 
be  estimated  and  allowed  for.  The  cost  of  the  food  is  an  important 
item.  It  must  be  borne  in  mind  that  it  is  often  possible  to  supply  a 
very  acceptable  meal  at  a  moderate  cost  where  more  expensive  articles 
of  diet,  while  they  might  seem  more  desirable,  would  not  answer  the 
purpose  so  well.  The  food  must  be  suited  to  the  digestive  powers  of 
the  consumers,  and  must  be  served  in  as  attractive  and  digestible  a 
form  as  possible.  It  must  be  remembered  that  while  the  number  of 
calories  required  may  be  estimated,  the  food  representing  this  amount 
must  be  supplied  in  such  form  that  it  can  be  utilized  by  the  individual 
receiving  it.  Atwater's  standards  for  the  various  classes,  as  given 
below  under  Prison  Diet,  are  in  general  use  in  this  country.  A 
varying  percentage  is  allowed  for  shrinkage  and  waste.  This  is  usu- 
ally placed  at  about  10  per  cent,  of  the  total  energy.  Mrs.  Richards 
estimates  10  per  cent,  on  the  proteins  and  carbohydrates,  and  makes 
no  allowance  on  the  fats  (in  the  standards  given  below).  Very  com- 
plete dietary  studies  have  been  made  by  Atwater  in  the  hospitals  for 
the  insane  in  New  York  State.  These  studies  are  published  in  the 
reports  of  the  New  York  State  Commission  in  Lunacy  for  1897-98, 
1898-99,  and  1899-1900.  The  pecuniary  advantage '  alone  of  this 
study  is  apparent  from  the  fact  that  there  was  a  reduction  of  $2.19 
per  capita  notwithstanding  that  the  cost  of  food-products  was  higher 

734 


PRISOX  DIETARIES  735 

than  usual.  The  patients  are  better  fed,  and  the  diet  is  such  as  is 
best  suited  to  their  condition  and  surroundings. 

Atwater  has  suggested  as  a  new  profession  that  of  dietary  expert. 
This  is  a  field  for  which  women  are  perhaps  particularly  well  adapted. 
The  dietary  expert  is  neither  a  cook  nor  an  ordinary  steward,  but 
should  be  an  individual  who  has  had  sufficient  training  along  special 
lines  to  enable  him  to  purchase  food,  formulate  suitable  and  accurate 
diet-lists,  supervise  the  keeping,  cooking,  and  serving  of  food,  so  as 
to  obtain  the  best  results,  reducing-  the  amount  of  waste  to  a  mini- 
mum, and  securing  as  great  a  degree  of  perfection  in  the  preparation 
of  the  food  as  it  is  possible  to  obtain. 

Basic  Quantity  Food  Tables.— Any  one  having  to  feed  any  num- 
ber of  individuals  from  two  up  in  institutions  should  not  be  without 
the  very  excellent  Basic  Quantity  Food  tables  to  be  used  in  determin- 
ing the  daily  issue  of  food  to  the  kitchen,  prepared  for  the  use  of 
institutions  by  the  Department  of  Public  Charities  of  the  City  of  New 
York,  and  issued  July,  1917,  and  to  be  had  from  the  Municipal 
Reference  Library,  512  Municipal  Building,  New  York  City.  The 
price  is  .$1.25. 

This  book  gives  the  tables  for  officers  and  staff,  nurses,  employees, 
inmates  and  patients,  tuberculous  patients,  feeble-minded  and  epi- 
leptic children  in  hospitals,  lodgers,  and  industrial  workers  at  Munic- 
ipal Lodging  House.  The  tables  show  the  daily  per  capita  allow- 
ance and  the  amount  that  is  to  be  sent  to  the  kitchen  for  the  varying 
number  of  individuals  that  have  to  be  served. 

PRISON  DIETARIES 

The  subject  of  Prison  Diet  has  received  considerable  attention,  and 
the  literature  on  the  subject,  although  very  large,  is  more  or  less 
inaccessible,  being  scattered,  for  the  most  part,  throughout  the  reports 
of  prisons  and  reformatories. 

Numerous  views  have  been  expressed  regarding  what  constitutes 
a  proper  diet  for  a  prisoner.  In  England  the  standards  recommended 
by  the  committee  appointed  by  the  Commissioners  of  Prisons  in  1878 
were  follow^ed  for  many  years.  The  plan  that  was  pursued  was  to 
divide  the  prisoners  into  four  classes : 

Class  I. :  Those  confined  for  periods  of  seven  days  and  less. 

Class  II. :  Those  confined  for  periods  of  more  than  seven  days  and 
not  more  than  one  month. 

Class  III. :  Those  confined  for  periods  of  more  than  one  month  and 
not  more  than  four  months. 

Class  IV. :  Those  confined  for  periods  of  more  than  four  months. 

This  division  was  made  in  order  to  prevent  those  serving  short 
sentences  from  receiving  a  full  dietary.  Since  such  prisoners  are 
for  the  most  part  drunken  and  disorderl}'  persons,  it  was  held  that 


736 


DIETARIES  ly  PUBLIC  IXSTITUTIOMS 


they  might  seek  to  be  committed  to  prison  for  the  sake  of  enjoying 
a  short  sentence  with  an  abundant  supply  of  food.  Under  the  Prison 
Commission's  plan  all  the  prisoners  began  with  the  first  dietary  after 
seven  days,  and  if  they  were  still  in  prison,  they  were  put  on  the 
second,  and  so  on.  This  plan  is  not  a  good  one,  for  it  would  seem 
better  to  place  all  long-term  prisoners  at  once  on  a  sufficient  and  ap- 
propriate diet. 

Prison  dietaries  are  now  formulated  according  to  the  standards 
fixed  for  a  healthy  free  man  doing  the  same  kind  of  labor.  The 
following  table,  taken  from  Atwater,^  gives  these  standards: 


Proposed  Dietary  Standards  for  Adults. 
(Quantities  per  man  per  day  unless  otherwise  stated.) 


Class. 


Persons  in  health  under  ordinary  conditions : 

Man "  at  hard  muscular  work 

Man  °  at  moderately  active  muscular  work 

Man '  with  light  muscular  woi-k     .... 

Man "  with  sedentary  work  ....... 

Man "  with  very  little  exercise 

Inmates  of  prisons,  insane  hospitals,  etc. : 

Male "  convicts  at  hard  work      

Ordinary  male  prisoners 

Prisoners  and  inmates  of  houses  of  correc- 
tion, per  person  : 

Inmates  of  reformatories  (male)     .... 

Unemployed  male "  prisonere 

Inmates  of  almshouses,  per  person     .    .    . 

Punitive  diet,  short  duration 

Punitive  diet,  long  duration 

The  insane,  per  person 

The  insane,  per  pereon 


By  whom 
proposed. 

a 
'3 
o 

3 

2=3.9 
•■s°* 

2  *  o 

>  (Up- 

< 

Om. 

Om. 

Calor- 
ies. 

Atwater  <* 

150 

138 

4350 

Atwater  <* 

125 

115 

3400 

Atwater  "* 

112 

102 

3050 

Atwater '' 

100 

92 

2700 

Atwater  "^ 

90 

72 

2450 

Dunlop  * 
Dunlop ' 

150 
120 

138 
110 

3^00 
3020 

Richards-^ 

103 

95 

2765 

Richards^ 

111 

102 

3000 

Dunlop  * 
Richards-'' 

90 
83 

83 
76 

2385 
2435 

Dunlop  * 
Dunlop  * 
Richards-'' 

64 

90 

110 

69 

82 

101 

1805 

2385 
3015 

Atwater  "^ 

85 

78 

2450 

(")  Assuming  92  per  cent,  digestible,  the  average  in  ordinary  mixed  diet. 

(*)  These  figures  are  about  3  per  cent,  smaller  than  have  been  given  pre- 
viously, the  difference  being  due  to  the  adoption  of  revised  factors  for  calcula- 
tions. 

{")  Corresponding  values  for  a  woman  are  0.8  as  much. 

(•*)  Figures  represent  physiologic  demand. 

(•)  Figures  represent  pi-actically  physiologic  demand,  there  being  but  an 
extremely  small  allowance  for  waste. 

(•'')  Figures  represent  ration  allowance,  with  margin  for  waste  of  about  10 
per  cent. 

One  of  the  most  vakiable  studies  of  prison  dietaries  is  that  made 
by  Dr.  J.  C.  Dunlop  for  the  Scottish  Prison  Commission,  and  pub- 
lished in  1899  as  a  "blue  book."  His  standards  are  based  on  careful 
investigation,   and  upon  actual  experiment  have  been  found  to  be 

1  Year-book  of  the  Department  of  Agriculture,  1901. 


PKIISOy  DIETARIES 


737 


satisfactory.  They  have  been  adopted  in  Scotland.  His  changres  in 
the  dietary  previously  furnished  are  based  on  the  amount  of  labor, 
sex,  age,  and  similar  conditions. 

I?unlop's  Dietary  Standards  for  Prisonert. 


Ordinary  male  prisoners 

Ordinary  female  prisoners 

Ordinary  female  prisoners  nui-sing 

Juveniles 

Male  prisonei-s  unemployed  or  practically  so  .    . 
Female  prisoners  unemployed  or  practically  so 

Male  convicts  at  active  labor 

Male  convicts  at  less  active  labor 

Female  convicts • 

Punishment  diets,  short  punishment  (subsistence) 
Punishment  diets,  longer,  with  light  work  .    .    . 


a 
2 

Ph 

i 

5-= 

120 

38 

550 

96 

30 

440 

105 

54 

482 

75 

43 

325 

90 

30 

440 

72 

23 

330 

150 

65 

550 

120 

50 

550 

100 

41 

440 

64 

21 

341 

90 

30 

440 

3100 

2480 
2910 
2040 
2400 
1860 
3500 
3200 
2600 
1850 
2400 


Note. — Standards  for  criminal  lunatics  and  sick  prisoners,  being  unneces- 
sary, are  not  included. 

Dunlop's  dietaries,  since  they  represent  complete  classified  lists 
made  on  a  scientific  basis  and  proved  by  experience,  are  here  given  in 
full.  No  hospital  dietary  is  given,  that  being  left  entirely  to  the 
discretion  of  the  medical  officer. 


DUNLOP'S  PRISON  DIETARIES  IN  USE  IN  SCOTTISH  PRISONS. 

Rate  I. 

All  ordinary  prisoners  under  sentence  of  imprisonment  for  not  longer  than 
three  days. 

Breakfast — Daily :  Gruel    1  pint. 

Bread    4  ounces. 

Dinner —      Sunday :  Broth    1  pint. 

Bread    6  ounces. 

Monday :  Pea  soup    1  pint. 

Bread    6  ounces. 

Tuesday :  Broth    1  pint. 

Bread    6  ounces. 

Wednesday:     Pea  soup    1  pint. 

Bread    6  ounces. 

Thursday :        Broth    1  pint. 

Bread    6  ounces. 

Friday:  Milk    f  pint. 

Bread    8  ounces. 

Saturday:        Pea  soup    1  pint. 

Bread    6  ounces. 

Supper —     Daily :  Gruel     1  pint. 

Bread    4  ounces. 

Rate  II. 

Male  ordinary  prisoners  with  sentences  above  three  days,  and  not  exceeding 
one  calendar  month. 

Female  and  juvenile  ordinary  prisoners  untried,  or  with  sentences  above  three 
days  and  not  exceeding  six  calendar  months. 
47 


738 


DIETARIES  ly  PUBLIC  lySTITUTIOyS 


Breakfast— Daily :  Porridge     5     ounces,  meal  ration. 

Milk    I  pint. 

Dinner —      Sunday:  Broth    I2  pints. 

Bread    0     ounces. 

Monday:  Pea  soup    li  pints. 

Bread    IJ     ounces. 

Tuesday:         Broth    IJ  pints. 

Bread    •>     ounces. 

Wednesday:    Pea    soup    IJ  pints. 

Bread    6     ounces. 

Thursday:       Broth    IJ  pints. 

Bread    6     ounces. 

Friday :  Potato     2A  pounds. 

Milk    I  pint. 

Saturday:       Pea  soup    IJ  pints. 

Bread    6     ounces. 

Supper —      Daily :  Porridge     5     ounces,  meal  ration. 

Milk    I  pint. 

Bate  III. 

Male  ordinary  prisoners  untried,  or  with  sentences  above  one  calendar  month 
and  not  exceeding  four  calendar  months. 

Female  and  juvenile  ordinary  prisoners  with  sentences  above  six  months. 

Male  ordinary  prisoners  employed  all  day  at  active  labor  in  the  open  air;  also 
those  employed' in  workshops  and  laundries  or  nursing,  with  sentences  from  three 
days  to  one  calendar  month. 

Female  ordinary  prisoners  employed  as  nurses  or  in  laundries  with  sentences 
from  three  days  to  six  months. 

Female  convicts  on  probation. 

Breakfast — Daily:  Porridge     8     ounces,  meal  ration. 

Milk    I  pint. 

Dinner —      Sunday:  Broth    2     pints. 

Bread    8     ounces. 

Monday:         Pea  soup   2     pints. 

Bread    8     ounces. 

Tuesday :         Broth    2     pints. 

Bread    8     ounces. 

Wednesday:    Pea   soup    2     pints. 

Bread    8     ounces. 

Thursday:       Broth    2     pints. 

Bread    8     ounces. 

Friday:  Potato    24  pounds. 

Milk    I  pint. 

Bread    4     ounces. 

(or  fish  dinner) . 
Saturday:       Pea  soup    2     pints. 

Bread    8     ounces. 

Supper —      Daily:  Porridge     5     ounces,  meal  ration. 

Milk    J  pint. 

Rate  IV. 

Male  ordinary  prisoners  with  sentences  above  four  months,  and  male  convicts 
in  probation  and  not  on  public  works. 

Brvakfast — ^Daily :  Porridge     8  ounces,  meal  ration. 

Milk    I  pint. 

Dinner —      Sunday :  Broth    2  pints. 

Bread    12  ounces. 

Monday :  Pea  soup    2  pints. 

Bread    12  ounces. 

Tuesday:         Broth    2  pints. 

Bread    12  ounces. 


PKIiSON  DIETARlEiS 


739 


Supper- 


Wednesday :    Pea  soup    2     pints. 

Bread    12     ounces. 

Thursday :       Broth    2     pints. 

Bread    12     ounces. 

Friday:  Potato     2i  pounds. 

Milk    I  pint. 

Bread    8     ounces. 

(or  fish  dinner) . 
Saturday :       Pea  soup    2     pints. 

Bread    12     ounces. 

Daily :  Porridge     6     ounces,  meal  ration. 

Milk    ^  pint. 

Rate  V. 


Female  convicts  not  in  the  probation  class. 


Breakfast — Sunday : 
Tuesday : 


Dmner — 


Thursday: 
Saturday : 
Monday : 
Wednesday ; 
Friday: 
Sunday : 

Monday : 


Tuesday : 
Wednesday : 
Thursday : 

Friday : 


Saturday : 
Supper —       Daily : 


Tea     ^  pint. 

Bread     8     ounces. 

Tea     ^  pint. 

Bread     8  ounces. 

Cheese    1  ounce. 

Broth     IJ  pints. 

Bread     8  ounces. 

Beef    6  ounces. 

Potato    1  pound. 

Bread     6  ounces. 

Beef   6  ounces. 

Bread     8  ounces. 

Pea  soup li  pints. 

Bread     8  ounces. 

Beef   6  ounces. 

Potato   1  pound. 

Bread     6  ounces. 

Fish   12  ounces. 

Potato   1  pound. 

Bread     6  ounces. 

Beef    (]  ounces. 

Bread     8  ounces. 

Porridge    6  ounces,  meal  ration. 

Milk     i  pint. 


Rate  VI. 
Male  convicts  not  on  probation  and  employed  at  indoor  industrial  labor. 

Breakfast — Daily :  Porridge     8     ounces,  meal  ration. 

Milk    I  pint. 

Dinner —      Sunday:  Pea  soup      IJ  pints. 

Bread    10     ounces. 

Cheese     1 J  ounces. 

Monday:  Beef     • 6     ounces. 

Broth    1     pint. 

Potato     1     pound. 

Bread    4     ounces. 

Tuesday:         Beef     6     ounces. 

Broth    1     pint. 

Bread    6     ounces. 

Wednesday :   Beef    6     ounces. 

Broth    1     pint. 

Potato     1     pound. 


.740 


DIETARIES  /A'  PUBLIC  INSTITUTIONS 


Bread    4  ounces. 

Thursday :       Beef    6  ounces. 

Rice   soup    1  pint. 

Cabbage i     1  pound. 

Bread    4  ounces. 

Friday :  Beef     6  ounces. 

Broth    1  pint. 

Potato     1  pound. 

Bread    4  ounces. 

Saturday :       Beef     6  ounces. 

Broth    1  pint. 

Bread    6  ounces. 

Supper —      Daily :  Coffee f  pint. 

Bread    12  ounces. 

Rate  VII. 
Male  convicts  employed  at  hard  labor  at  public  works. 

Breakfast — Daily :  Porridge     8  ounces,  meal  ration. 

Milk    I  pint. 

Dinner —      Sunday:  Pea  soup    l|  pints. 

Bread    12  ounces. 

Cheese     IJ  ounces. 

Monday :         Beef    7  ounces. 

Broth    1  pint. 

Potato     1  pound. 

Bread    6  ounces. 

Tuesday:         Beef    7  ounces. 

Broth    1  pint. 

Jread    8  ounces. 

Wednesday :    Beef     7  ounces. 

Broth    1  pint. 

Potato     1  pound. 

Bread    6  ounces. 

Thursday :       Beef 7  ounces. 

Rice  soup 1  pint. 

Cabbage  2 1  pound. 

Bread    6  ounces. 

Friday :  Beef 7  ounces. 

Broth    1  pint. 

Potato 1  pound. 

Bread    &  ounces. 

Saturday :       Beef 7  ounces. 

Broth    1  pint. 

Bread    8  ounces. 

Supper —      Daily:  Coffee    1  pint. 

Bread    12  ounces. 

Rate  VIII. 
For  male  convicts  at  light  labor. 

Breakfast — Daily :  Porridge     8     ounces,  meal  ration. 

Milk    I  pint. 

Dinner —      Sundays  Pea  soup    l|  pints. 

Bread    10     ounces. 

Cheese     li  ounces. 

Monday :  Beef     4     ounces. 

1  An  equal  amount  of  carrot,  turnip,  turnip-tops,  leeks,  parsnips,  or  other  fresh 
vegetables  may  be  substituted. 

2  An  equal  amount  of  carrot,  turnip,  turnip-tops,  leeks,  parsnips,  or  other  fresh 
vegetables  may  be  substituted. 


PRISON  DIETARIES 


741 


Broth    1  pint. 

Potato     1  pound. 

Bread    4  ounces. 

Tuesday :         Beef    4  ounces. 

Broth    1  pint. 

Bread    6  ounces. 

Wednesday :    Beef    4  ounces. 

Broth    1  pint. 

Potato     1  pound. 

Bread    4  ounces. 

Thursday:       Beef     4  ounces. 

Rice   soup    1  pint. 

Cabbage    1  pound. 

Bread    4  ounces. 

Friday :  Beef     4  ounces. 

Broth     1  pint. 

Potato     1  pound. 

Bread    4  ounces. 

Saturday :       Beef     4  ounces. 

Broth    1  pint. 

Bread    6  ounces. 

Supper —       Daily :  Coffee      I  pint. 

Bread    12  ounces. 

Kate  IX. 

(A)  Prisoners  under  punishment  for  prison  offences  for  terms  not  exceeding 
three  days. 

Breakfast — Bread 8  ounces. 

Dinner —      Bread 4  ounces. 

Supper —      Bread 4  ounces. 

(B)  Prisoners  under  punishment  for  prison  offences  for  terms  exceeding  three 
days. 

Breakfast — Gruel 1  pint. 

Bread 8  ounces. 

Dvnner —      Bread 8  ounces. 

Supper —      Gruel 1  pint. 

Bread 8  ounces. 

Criminal  Lunatic  Department. — Where  the  amount  of  ration  is 
not  stated  that  food  is  allowed  ad  libitum.  This  does  not  apply  to 
butter,  of  which  8  ounces  weekly  are  to  be  allowed  for  each  inmate. 

Rate  X. 

Breakfast —  Porridge  8  ounces,  meal  ration.i 

Sweet   milk    |  pint. 

Skimmed  milk    |  pint. 

Tea    

Bread    

Butter     

Dinner —      Sunday :  2        Broth    1^  pints. 

Bread    

Cheese     2     ounces. 

Monday :  Pea  soup    1     pint. 

Beef     6     ounces. 

Potato     

Bread    

Tuesday :         Pork  or  mutton   6     ounces. 

Broth    1     pint. 

1  For  female  convicts  6  ounces,  meal  ration. 

2  The  medical  superintendent  shall  have  power  to  alter  the  Sunday  dinner. 


742 


DIETARIES  IN  PUBLIC  INSTITUTIONS 


Supper — 


Potato  1    

Bread    

Wednesday :    Beef    6     ounces. 

Potato     

Pudding    

Bread    

Thursday :       Broth    1     pint. 

Beef     6     ounces. 

Potato  1    

Bread    

Friday:  Fish     12     ounces. 

Potato     

Bread    

Pudding    

Saturday :       Pea  soup    1     pint. 

Beef     6     oiinces. 

Potato     

Bread    

Daily :  Tea  or  coffee 

Bread    

Butter    

Food-value  of  Dunlop^s  Dietary  Average  per  Diem. 


Kate  I 

Rate  II 

Kate  II.  with  fat  dinner 

Kate  II.  vviiii  sweet  milk  .  .  .  . 
Kate  II.  with  sweet  milk  and  fish 
Kate  III 

V\'ith  fish  dinner 

Kate  IV.    .    .        

With  fish  dinner 

KateV 

Kate  VI 

Rate  VII 

KateVIU 

Kate  IX 


Protein. 

Fat. 

Carbo- 
hydrates. 

Energy 

value, 

calories. 

67.30 

10.12 

352.18 

1810 

91.82 

25.52 

362.55 

2099 

98.82 

25.47 

357.60 

2114 

106.03 

54.37 

453.46 

2799 

113.33 

54.03 

448.51 

2804 

117.81 

32.77 

470.56 

2715 

123.49 

32.60 

459.08 

2690 

134.60 

35.50 

535.51 

3115 

139.56 

35.31 

519.16 

3067 

120.63 

42.53 

402.13 

2542 

153.93 

50.62 

536.08 

3300 

165.44 

56.54 

566.00 

3525 

143.18 

39.24 

536.08 

3149 

82.62 

10.28 

456.24 

2313 

"The  following  alternative  and  extra  diets  are  to  be  allowed: 

*'l.  Male  prisoners  of  more  than  168  pounds  weight  (partly  clothed) 
receiving  Rates  IV.,  VI.,  VII.,  or  VIII.,  and  female  prisoners  of 
more  than  154  pounds  weight  (partly  clothed)  receiving  Rates  III. 
or  v.,  shall  receive  as  an  extra  1  ounce  cheese  and  4  ounces  bread 
daily. 

"2.  Female  prisoners  nursing  infants  at  the  breast  shall  receive 
Rate  III.,  with  one  pint  sweet  milk  daily  additional. 

"3.  Prisoners  with  sentences  of  more  than  one  year  may  have 
after  nine  months  in  prison  a  supper  consisting  of  %  pint  of  tea  or 
coffee  and  12  ounces  bread  daily  instead  of  the  porridge  supper. 
This  regulation  does  not  apply  to  prisoners  in  Peterhead  Convict 
Prison,  nor  to  women  with  sentences  of  penal  servitude  in  Perth 
Prison. 

1  Cabbage  or  other  fresh  vegetables  may  be  substituted  for  potatoes. 


PKIl^ON  DIETARIES  743 

**4.  Prisoners  receiving  Rates  III.  and  IV.,  with  sentences  of  more 
than  four  months,  may  receive  a  fish  dinner  once  weekly.  The  fish 
dinner  shall  consist  of  12  ounces  fresh  fish,  or  6  ounces  dried  fish, 
with  1  pound  potatoes  and  6  ounces  bread  with  Rate  III.  diet,  and  8 
ounces  with  Rate  IV.  diet. 

"5.  When  employed  in  the  laundry,  at  the  baths,  and  in  the  recep- 
tion rooms,  females  may  receive  i/4  piiit  tea  between  breakfast  and 
dinner,  and  the  same  between  dinner  and  supper. 

"6.  Male  prisoners  employed  for  two  hours  or  more  in  the  open 
air  before  breakfast  shall  receive  6  ounces  bread  and  %  pint  milk 
before  beginning  work. 

"7.  The  prison  medical  officers  shall  have  power,  should  occasion 
arise,  to  increase  or  alter  the  diets  of  individual  prisoners,  and  to 
reduce  the  diets  of  individual  prisoners  should  they  be  satisfied  that 
those  prisoners  are  persistently  wasting  food." 

The  following  directions  relate  to  the  foregoing  dietaries,  viz. ; 

"1.  Each  pint  of  soup  must  contain:  (1)  1  ounce  marrow  bones 
or  oxhead  or  I/2  ounce  hough,  neck  of  beef,  or  other  meat,  and  (2) 
be  seasoned  with  pepper  in  a  proportion  not  exceeding  1  ounce  to 
100  pints  and  with  salt  1  pound  to  100  pints.  The  first  of  these  di- 
rections does  not  apply  to  soups  served  with  the  meat  dinners  of  Rates 
VI.,  VII.,  and  VIII. 

"2.  Each  pint  of  broth  shall  contain  IV2  ounces  of  barley,  I/2 
ounce  of  green  peas,  II/2  ounces  of  leeks,  carrots,  turnips,  or  other 
similar  vegetables,  as  may  be  most  easily  procured,  and  14  ounce  of 
onion. 

''3.  Each  pint  of  pea  soup  shall  contain  2  ounces  of  split  peas, 
14  ounce  of  pease  meal,  I/4  ounce  of  onion  or  leeks,  14  ounce  of  carrots 
or  turnips. 

"4:.  Each  pint  of  rice  soup  shall  contain  2  ounces  of  rice  and  i^ 
ounce  chopped  parsley. 

"5.  Peas,  barley,  and  rice  to  be  well  soaked  before  being  used,  and 
when  served  the  peas  ought  to  be  perfectly  soft. 

' '  6.  All  vegetables  to  be  cut  and  washed  before  being  weighed. 

"7.  Potatoes  should  be  cleaned,  divided  in  half,  and  freed  from 
bad  ones  before  being  weighed.  Especial  care  must  be  taken  to 
preserve  the  potatoes  so  that  they  shall  not  vegetate  or  be  injured  in 
any  way. 

"8.  Gruel  when  made  in  quantities  exceeding  50  pints  shall  con- 
tain 11/2  ounces  of  oatmeal  per  pint ;  when  made  in  smaller  quantity 
2  ounces  oatmeal  per  pint.  Gruel  to  be  seasoned  with  salt  and  sweet- 
ened with  %  ounce  sugar  per  pint. 

*'9.  Each  pint  of  tea  to  be  made  from  I/4  ounce  of  tea,  1  ounce  of 
sugar,  and  14  gill  of  sweet  milk. 

"10.  Each  pint  of  coffee  to  be  made  from  1^  ounce  of  ground  coffee, 


744  DIETARIES  IN  PUBLIC  INtSTITUTIO:SS 

%  ounce  sugar,  and  I/2  gill  of  sweet  milk.  Some  chicory  may  be  used 
with  the  coffee  and  weighed  as  such. 

"11.  Pudding  (Rate  IX.)  to  be  either  rice  or  bread  crumb.  Rice 
pudding  to  contain  11/2  ounce  rice,  y^  ounce  sugar,  and  %o  pi^it 
sweet  milk.  Bread-crumb  pudding,  2  ounces  of  bread  crumb,  Yo 
ounce  of  currants,  li/^  ounce  flour,  1  oi*^e  suet,  and  1  ounce  sugar 
for  each  person.  ^■li^'^ 

"12.  Meat  to  be  weighed  without  bone  a^HKore  being  cooked. 

"13.  Fish  to  be  weighed  after  being  clSKct  and  trimmed,  but 
before  being  cooked. 

"14.  The  vessels  in  which  the  food  is  distributed  may  be  collected 
half  an  hour  alter  the  prisoners  have  received  them,  except  with 
dinner,  when  forty  minutes  must  be  allowed.  All  unconsumed  rem- 
nants of  food  must  be  removed  from  the  cells. 

"15.  In  the  event  of  the  following  articles  of  diet  not  being  readily 
obtainable  or  excessive  in  price,  the  undernamed  substitute  may  be 
used : 

^^ Buttermilk. — Substitute  skimmed  or  separated  milk  in  equal  quan- 
tity, or  failing  these,  2  ounces  of  cheese  for  each  milk  ration  and  1 
ounce  sugar  should  that  milk  ration  be  due  for  a  porridge  meal. 

*' Potato. — Substitute  2  ounces  rice  and  8  ounces  fresh  vegetable 
for  1  pound  potato,  or  failing  fresh  vegetable,  4  ounces  rice. 

"Cabbage  or  Other  Vegetable  (Rates  VI.,  VII.,  and  VIII.).— 
Substitute  4  ounces  bread  for  1  pound  cabbage  or  other  vegetable." 

American  Prison  Dietaries. — There  is  no  dietary  that  can  specifi- 
cally be  called  American.  In  the  best  ordered  prisons  the  dietaries 
are  based  on  Atwater's  standards.  In  many  States  the  diet  is  left 
to  the  steward  of  the  prison,  and  no  particular  method  is  followed. 
Details  will  be  found  in  the  reports  of  the  various  institutions  and 
also  in  the  reports  of  conventions  of  charities  and  corrections. 

English  Prison  Dietaries. — The  Committee  of  1899  condemns  the 
utilization  of  diet  as  a  means  of  punishment,  but  recommends  what 
amounts  to  the  same,  i.  e.,  that  the  diet  of  prisoners  who  are  sentenced 
for  a  term  of  less  than  three  weeks  be  smaller  than  that  of  those  who 
are  sentenced  for  three  months  or  longer.  For  short-term  prisoners 
they  recommend  that  the  diet  be  "adequate  in  amount  and  kind  to 
maintain  health  and  strength  during  the  single  week,"  but  it  is  not 
to  be  made  attractive  to  the  "loafer"  or  mendicant.  -The  progressive 
system  formerly  in  use  is  now  condemned.  The  diet  is  to  be  adequate 
to  nourish  the  body  and  maintain  strength,  so  that  at  the  end  of  his 
term  the  prisoner  may  be  in  condition  to  return  to  his  occupation. 
For  fourteen-day  sentences,  however,  the  prisoner  is  kept  the  first 
seven  days  on  a  spare  diet,  and  for  the  remaining  seven  receives  a 
somewhat  fuller  diet. 

The  Committee  recognizes  that  the  nature  of  the  work  the  prisoner 
is  doing  should  be  considered,  but  does  not  attempt  to  make  any 


PRISOy  DIETARIES  745 

dietaries  for  local  prisons  along  these  lines;  since,  therefore,  the  diet 
intended  for  prisoners  at  ordinary  labor  is  barely  sufficient,  the  pris- 
oner at  hard  labor  would,  on  the  same  diet,  be  underfed.  The  diet 
thus  becomes  a  mode  of  punishment  again,  a  practice  that  is  to  be 
condemned. 

The  same  Report  advises  a  ditt'erent  diet  for  men,  women,  and 
children.  Dunlop  gives  the  following  resume  of  the  English  prison 
dietaries. 

Ordinary  Prisoners'  Dietaries. — The  dietaries  recommended  in  the 
report  for  ordinary  prisoners  are  no  fewer  than  nine;  three  classes, 
A,  B,  and  C,  each  class  with  three  dietaries — No.  1  for  men.  No.  2  for 
women,  and  No.  3  for  juveniles. 

'^  Class  A  Dietaries. — For  prisoners  with  sentences  of  not  more  than 
seven  days,  and  for  prisoners  with  sentences  of  not  more  than  four- 
teen daj^s  during  the  first  seven  days  of  their  imprisonment.  These 
dietaries  are  described  in  the  Committee's  report  as  'of  the  plainest 
food,  unattractive,  but  good  and  wholesome  and  adequate  in  amount 
and  kind  to  maintain  health  and  strength  during  the  single  week.' 
They  consist  of  bread  and  gruel  for  breakfast  and  supper,  and  bread 
with  either  potato  or  porridge  or  suet  pudding  for  dinner.  An  al- 
lowance of  milk  is  given  as  an  extra  to  juveniles.  The  daily  food- 
value  is  estimated  by  the  Committee  as  consisting  of — For  men,  pro- 
tein 3.88  ounces  (109  grams)  ;  carbohydrate,  17.08  ounces  (484.22 
grams)  ;  fats,  0.89  ounces  (25.23  grams)  ;  for  women,  protein,  2.71 
ounces  (79.38  grams)  ;  carbohydrate,  13.71  ounces  (391.22  grams)  ; 
fats,  0.74  ounces  (20.97  grams)  ;  for  juveniles,  protein,  3.93  ounces 
(111.40  grams)  ;  carbohydrate,  14.67  ounces  (415.87  grams)  ;  fats, 
1.48  ounces  (41.94  grams).  The  energy  value  of  such  diets  is  found 
by  calculation  to  be  as  follows :  For  men,  2667  calories ;  for  women, 
2124  calories;  and  for  juveniles,  2552  calories.  A  comparison  with 
the  standards  of  prisoners'  food  requirements  (vide  p.  14  of  this  re- 
port) shows  that  the  diet  for  men  is  insufficient  except  when  the 
men  are  almost  idle,  that  the  diet  for  women  is  also  insufficient  except 
when  the  women  are  idle,  but  that  the  diet  for  juveniles  is  sufficient.^ 
From  the  fact  that  Class  A  Diets  are  insufficient  for  working  men 
and  women,  it  follows  that  these  introduce  a  distinct  penal  element 
into  the  dietary  regulation.  It  may  be  urged  that  slight  underfeeding 
for  a  limited  time  does  no  serious  harm.  That  may  be  so,  but  an 
insufficient  diet  is  essentially  a  penal  diet ;  shortening  the  application 
cannot  make  an  insufficient  diet  a  sufficient  one,  and  therefore  an 
insufficient  diet  for  even  a  short  application  is  a  penal  diet. 

''Class  B  Diets. —  (1)  For  prisoners  with  sentences  of  more  than 
seven  days  and  less  than  fourteen  days  after  the  expiry  of  seven  days 

1  "The  Committee  compare  their  dietaries  with  Konig's  standard  for  moderate 
work.  His  male  standard  contains  practically  the  same  amount  of  protein  as 
the  standard  I.  gives  for  moderate  work,  but  has  more  fat  and  less  carbohydrate 
than  mine.     The  energy  value  is  practically  the  same." 


746  DIETARIES  IN  PUBLIC  INSTITUTIONS 

of  their  sentence;  (2)  for  prisoners  with  sentences  of  more  than 
fourteen  days  and  not  more  than  three  months ;  (3)  for  untried  prison- 
ers, offenders  of  the  first  division  who  do  not  maintain  themselves, 
offenders  of  the  second  division,  and  debtors  (untried  prisoners  and 
offenders  of  the  first  division  receive  tea  or  cocoa  instead  of  gruel  or 
porridge  for  breakfast  and  supper).  These  diets  consist  of  bread 
and  gruel  for  breakfast,  bread  and  potato  with  either  tinned  meat 
or  beans  and  bacon,  or  soup,  or  suet  pudding,  or  cooked  beef  for 
dinner,  and  bread  with  either  porridge,  gruel,  or  cocoa  for  supper. 
Juveniles  are  allowed  a  small  quantity  of  milk  for  breakfast.  The 
food-value  of  these  diets  as  calculated  by  the  Committee  is — for  men, 
protein,  4.73  ounces  (133.8  grams)  ;  carbohydrate,  18.32  ounces 
(519.34  grams)  ;  fats,  1.38  ounces  (39.12  grams)  ;  for  women,  protein, 
3.94  ounces  (116.68  grams)  ;  carbohydrate,  11.87  ounces  (434.59 
grams)  ;  fats,  1.06  ounces  (30.05  grams)  ;  for  juveniles,  protein,  4.30 
ounces  (121.89  grams)  ;  carbohydrate,  19.15  ounces  (439.13  grams)  ; 
and  fats,  1.85  ounces  (50.74  grams).  The  energy  values  of  these 
diets  calculated  from  these  figures  are — for  men,  3098  calories;  for 
women,  2519  calories;  and  for  juveniles,  2772  calories.  A  comparison 
shows  that  these  three  dietaries  closely  approximate  to  the  standards 
for  men,  women,  and  juveniles  doing  a  moderate  day's  work. 

'^  Class  C  Diets. — For  all  ordinary  prisoners  with  sentences  of 
more  than  three  months.  These  diets  closely  resemble  those  of  Class 
B.  They  differ  by  having  large  allowances  of  some  of  the  dinner 
dishes,  as  potatoes,  beans,  and  suet  pudding,  and  by  cocoa  being  sub- 
stituted for  porridge  or  gruel  at  supper  time,  and  in  the  female  diet 
by  tea  being  given  instead  of  gruel  at  breakfast  time.  The  Committee 
estimate  the  daily  food-value  of  these  diets  as  follows :  That  for 
men,  protein,  4.90  ounces  (138.9  grams)  ;  carbohydrate,  19.15  ounces 
(542.87  grams)  ;  fat,  1.85  ounces  (52.44  grams)  ;  for  women,  protein, 
3.92  ounces  (111.11  grams)  ;  carbohydrate,  14.89  ounces  (422.12 
grams)  ;  fats,  1.61  ounces  (45.63  grams)  ;  for  juveniles,  protein,  4.59 
ounces  (130.11  grams)  ;  carbohydrate,  16.40  ounces  (464.94  grams)  ; 
and  fat,  2.05  ounces  (58.10  grams).  From  these  figures  the  energy 
value  of  the  diets  appear  to  be — for  men,  3283  calories;  for  women, 
2611  calories;  and  for  juveniles,  2980  calories.  These  three  dietaries 
may  all  be  described  as  being  in  excess  of  the  requirements  of  the 
standards  for  moderate  work." 

French  Prison  Dietaries. — The  French  use  the  canteen  system. 
Prisoners  having  private  means  and  working  prisoners  may  purchase 
from  the  canteen  certain  food-supplies  to  augment  the  ordinary  prison 
diet.  This  method  has  to  recommend  it  the  fact  that  it  tends  to 
make  the  idle  prisoner  work  harder,  but  it  has  the  disadvantage  that 
it  discriminates  between  the  poor  and  the  well-to-do  prisoner. 

The  French  prisoner  receives  daily  about  li/4  pounds  of  bread.  He 
is  given  two  meals  a  day — soup  at  9  a.  m.  and  a  dish  of  vegetables  at 


HOSPITAL  DIETARIES  747 

6  p.  M.  Meat  is  served  on  fete  da^'s  and  on  Sundays,  and  to  long- 
sentence  prisoners  on  Thursdays.  This  dietary,  without  the  extras, 
is  not  sufficient  for  a  working-man.  By  the  purchase  of  the  supplies 
allowed  it  maj'  be  rendered  ample.  From  the  canteen  the  prisoner 
may  purchase  daily  li/o  pounds  of  bread  and  a  portion  of  one  of  the 
following:  potatoes,  cheese,  butter,  milk,  salad,  fruit,  and  beef.  The 
daily  value  must  not  exceed  20  centimes  for  bread  and  15  centimes 
for  the  other  articles.  The  French  use  especial  diets  for  the  criminal 
insane,  for  the  sick  in  hospitals,  and  for  nursing  mothers. 

Prussian  Prison  Dietaries. — These  are  somewhat  similar  to  the 
French.  Three  meals  are  allowed  daily.  IMeat  is  used  sparingly,  and 
the  bulk  of  the  diet  consists  of  cereals  and  vegetables.  No  classifica- 
tion is  made,  so  far  as  is  known,  except  for  nursing  mothers,  for  those 
serving  sentences  of  less  than  four  days,  and  for  prison  offences. 

HOSPITAL  DIETARIES 

There  is  a  wide  variation  in  the  diet-lists  of  the  various  hospitals, 
dependent  on  the  size,  income,  management,  etc.,  of  the  institute. 
These  diet-lists  are  designated  by  various  names,  according  to  the 
persons  for  whom  they  are  intended  and  the  articles  of  which  they 
are  made  up. 

In  children's  hospitals  the  food  for  each  infant  should  be  prescribed 
individually.  For  convenience  those  over  one  year  and  under  two 
or  two  and  one-half  years  may  be  put  on  a  suitable  diet  designated  as 
"baby  diet."  For  older  children  the  designations  for  diets  are  the 
same  as  in  hospitals  for  adults. 

The  diets  in  use  in  the  average  American  hospitals  are  classified 
as  follows : 

Ward  Diet. — This  is  also  known  as  ''full"  or  "house  diet."  It  is 
the  ordinary  diet  of  all  patients  for  whom  special  diet  orders  have 
not  been  given.  (By  reference  to  the  hospital  diet-lists  given  below 
the  composition  of  the  various  diets  can  be  learned.) 

Light  diet,  also  known  as  convalescent  diet,  is  that  used  for  con- 
valescent patients  generally  and  for  others  for  whom  it  is  suitable. 
It  consists  of  milk,  broths,  eggs,  and  such  other  foods  as  are  easily 
digestible  yet  nutritious. 

Special  Diets. — Under  this  heading  are  included  dietary  formulas 
suitable  for  those  diseases  in  which  diet  plays  an  important  part  in 
the  treatment.  It  includes  such  diets  as  have  been  recommended  in 
certain  diseases,  and  which  bear  the  name  of  the  inventor,  as  Tufnell's 
diet  for  aneurysm.  Banting's  diet  for  obesity,  and  such  general  diets 
as  the  following: 

Milk  Diet. — This  is  composed  entirely  of  milk,  two  to  three  quarts 
usually  being  allowed  daily. 

Meat  Diet. — This  consists  chiefly  of  nitrogenous  animal  foods  with 


748  DIETARIES  I\  PUBLIC  lyiSTITUTIOyS 

a  minimum  of  sugars  and  starches.  It  is  useful  in  certain  diseases  of 
the  stomach  where  there  is  acid  fermentation.  It  closely  resembles 
the  diabetic  diet. 

Farinaceous  Diet. — This  is  made  up  of  milk,  butter,  and  carbo- 
hydrates. It  is  prescribed  for  convalescents  and  in  chronic  nephritis, 
etc. 

Special  or  extra  special  articles  of  diet,  as  they  are  often  termed, 
include  all  articles  not  on  the  regular  diet-list  for  the  day,  and  for 
which  special  orders  are  generally  given. 

It  is  a  fact  much  to  be  deplored  that  the  commissary  department  of 
many  large  hospitals  is  poorly  managed.  In  some,  special  hospital 
stewards  of  experience  are  appointed,  but  in  many  the  ordering  and 
the  preparation  of  the  meals,  and  often,  indeed,  the  distribution  of 
the  food  to  the  patients,  are  assigned  to  inexperienced  persons  who 
are  frequently  ignorant  of  the  requirements  of  the  patients.  As  a 
result,  errors  in  diet,  with  their  consequences,  are  common,  and  very 
often  there  is  waste  as  well.  In  a  large  hospital  a  competent  steward 
is  a  necessity  and  an  economy  as  well. 

The  physician  should  prescribe  the  diet  for  each  patient.  It  is  a 
fact  that  in  manj^  hospitals  Avhere  the  catering  is  not  deficient,  the 
diet  for  patients  is  selected  by  the  nurses,  with  the  exception,  per- 
haps, in  the  case  of  a  few  of  the  more  important  diseases,  such  as 
typhoid,  diabetes,  and  the  like.  The  conclusion  to  be  drawn  is  ob- 
vious. 

THE  JOHNS  HOPKINS  HOSPITAL  DIET  SHEET 

Breakfast.  8  a.m.:  Fruit,  cereal  (oatmeal,  hominy,  grits,  Wheatena),  chops, 
steak,  chicken    ( broiled ) ,  bacon,  fish,  potatoes,  rolls. 

Dinner,  1  P.  m.  :  Soup,  fish,  beef   (  roast ) ,  lamb   ( roast ) ,  mint  sauce,  chicken 

(roast),  turkey  (roast),  cranberry  sauce,  sweetbreads, 
salads  ( cress,  lettuce ) ,  tomatoes,  celery,  potatoes,  rice, 
vegetables,  dessert,  fruit. 

Tea,  6  p.  ir. :  Chicken,  chops,  steak,  fish,  potatoes,  rolls,  fruit. 

The  Johns  Hopkins  Hospital  Daily  Order  for  Ward 

Milk,  quarts  or  gallons    Mutton-broth,   pints    

Eggs,  dozen   Chicken-soup,  pints   


Butter,  pounds   Beefsteak 

Sugar,   pounds    Chickens     

Beef-tea,  pints    Lemons,   dozen 

Number,  of  patients  on 

Ward    diet    

Special   diet    

Light  diet    

Liquid  di^t   


Total 


.Head  Nurse. 


Weekly  Order. 
Special  Orders  for  Monday,  A.  M.: 

Tea     

Coffee     


HOSPITAL  DIETARIES 


749 


Cocoa    . . . 
Chocolate 


DIET  OF  THE  LAKESIDE  HOSPITAL,  CLEVELAND,  OHIO 
Doctors 

Breakfast:     Fruit,  wheat  gem  and   cream,   baked   beans,   eggs,   fish-balls,   brown 

bread,  toast,  coftee,  milk. 
Luncheon:      Scalloped  oysters,  potato,  cold  meat,  fruit  salad,  cake,  tea,  milk. 
Dinner:  Roast-beef,  Yorkshire  pudding,  potato,  squash,  celery,  lettuce,  Char- 

lotte Russe,  crackers  and  ciieese,  coffee,  milk. 
Breakfast :     Fruit,  oatmeal  and  cream,  broiled  chops,  eggs,  potato,  rolls,  toast, 

coffee,  milk. 
Luncheon:      Soup,  cream  chipped  beef,  baked  potato,  cold  meat,  fried  mush  and 

maple  syrup,  tea,  milk. 
Dinner:  Soup,  broiled  steak,  ]\Iaitre  d'  Hotel  sauce,  potato,  asparagus-tips  on 

toast,    olives,    lettuce,    mock    cherry    pie,    crackers    and    cheese, 

coffee,  milk. 
Breakfast:     Fruit,    oatmeal   and   cream,   broiled    fish,   eggs,   potato,    rolls,   toast, 

coffee,  milk. 
Luncheon:      Soup,    mutton    cutlets,    brown    sauce,    potato,    fruit-jelly,    whipped 

cream,  tea,  milk. 
Dinner:  Soup,    roast   duck,   jelly,    potato,    stewed    tomatoes,    olives,    lettuce, 

strawberry  ice-cream,  crackers  and  cheese,  cake,  coffee,  milk. 
Breakfast:     Fruit,  oatmeal  and  cream,  broiled  chops,  eggs,  potato,  rolls,  toast, 

coffee,  milk. 
Luncheon:      Soup,   egg  vermicelli   on   toast,   potato,  cold  meat,   boiled  rice  with 

cream  and  maple  syrup,  tea,  milk. 
Dinner:  Soup,   roast   lamb,    mint   sauce,   jelly,   potato,   string-beans,    lettuce, 

chocolate   pudding,    custard    sauce,   crackers    and    cheese,    coffee, 

milk. 
Breakfast:     Fruit,  oatmeal  and  cream,   broiled  steak,  eggs,   potato,   rolls,  toast, 

coffee,  milk. 
Luncheon:      Soup,  cod  a   la  mode,   potato,  cold  meat,  apple  sauce,   hot  muffins, 

cocoa  and  whipped  cream,  tea,  milk 
Dinner:  Soup,  roast  turkey,  cranberry  sauce,  potato,  mashed  turnip,  celery, 

lettuce,   "snow-balls,"   cream   sauce,   crackers   and   cheese,   coffee, 

milk. 
Breakfast :     Fruit,  oatmeal  and  cream,  scrambled  eggs  and  bacon,  potato,  rolls, 

toast,  coffee,  milk. 
Luncheon:      Clam  chowder,  potato,  cold  meat,  doughnuts  and  cheese,  tea,  milk. 
Dinner:  Soup,  roast-beef,  potato,  ftalian  spaghetti,  olives,  lettuce,  bisque  ice- 

cream, crackers  and  cheese,  cake,  coffee,  milk. 
Breakfast:     Oatmeal   and   cream,    Hamburger    steak,    mushroom    sauce,   eggs   on 

toast,  potato,  rolls,  toast,  coffee,  milk. 
Luncheon:      Soup,  Finnan  haddock,  potato,  cold  meat,  hot  biscuits,  honey,  tea, 

milk. 
Dinner:  Soup,   chicken   a   la   Maryland,   potato,   green   peas,   celery,   lettuce, 

French  fruit  pudding,  sauce,  crackers  and  cheese,  coffee,  milk. 
Breakfast:     Fruit,   wheat  gem  and   cream,   baked   beans,   eggs,   fish-balls,   brown 

bread,  toast,  coffee,  milk. 
Luncheon:      Oyster  stew,  lobster  salad,  potato,  cold  meat,  fruit-jelly,  cake,  tea, 

milk. 
Dinner:  Soup,  roast-beef,  potato,  squash,  olives,  lettuce,  Sultana  ice-cream, 

crackers  and  cheese,  cake,  coffee,  milk. 
Breakfast:     Fruit,  oatmeal  and  cream,  broiled  chops,  eggs,  potato,  rolls,  toast, 

coffee,  milk. 
Luncheon:      Soup,  hash,  cold  meat,  baked  apples,  cake,  tea,  milk. 
Dinner:  Soup,  roast  lamb,  mint  sauce,  jelly,  potato,  spinach,  lettuce,  tapioca 

cream,  crackers  and  cheese,  coffee,  milk. 
Breakfast:     Fruit,  oatmeal  and  cream,  broiled  ham  and  eggs,  potato,  rolls,  toast, 

coflFee,  milk. 


750 


DIETARIES  /A'  PUBLIC  INSTITUTIONS 


Luncheon:  Soup,  Frankfurter  sausage,  hot  slaw,  potato,  cold  meat,  banana  frit- 
ters and  maple  syrup,  tea,  milk. 

Dinner:  Soup,  broiled  chicken,  potato,  scalloped  corn,  celery,  lettuce,  caramel 

ice-cream,  crackers  and  cheese,  cake,  coffee,  milk. 

Breakfast:  Fruit,  oatmeal  and  cream,  broiled  steak,  eggs,  potato,  rolls,  toast, 
coffee,  milk. 

Luncheon:  Soup,  fried  scallops,  tartar  sauce,  potato,  cold  meat,  ginger-bread 
and  cheese,  tea,  milk. 

Dinner:  Soup,  roast-beef,  potato,  stewed  tomato,  olives,  lettuce,  apple  pie, 

crackers  and  cheese,  coffee,  milk. 


Iilurses 
Breakfast:     Oatmeal  and  cream,  broiled  ham,  potato,  rolls,  toast,  coffee,  cocoa. 
Luncheon:      Cold   meat,   horseradish    sauce,   potato,   banana   fritters   and   maple 

syrup,  tea,  milk. 
Dinner:  Soup,  braised  beef,  potato,  hot  slaw,  caramel  ice-cream,  cake,  coffee. 

Breakfast:     Oatmeal  and  cream,  creamed  fresh  fish,  potato,  rolls,  toast,  coffee, 

cocoa. 
Luncheon:      Beef-stew  with  dumplings,  ginger-bread  and  cheese,  tea,  milk. 
Dinner:  Soup,  roast-beef,  potato,  stewed  tomato,  apple  pie  and  cheese,  coffee. 

Breakfast:     Wheat  gems  and  cream,  baked  beans,  fish-balls,  brown  bread,  toast, 

coffee,  cocoa. 
Luncheon:      Scalloped  oysters,  potato,  prune  jelly,  tea,  milk. 
Dinner:  Soup,  roast-beef,  potato,  squash,  steamed  molasses  pudding,  nutmeg 

sauce,  coffee. 
Breakfast:     Oatmeal  and  cream,  creamed  fresh  fish,  potato,  rolls,  toast,  coffee, 

cocoa. 
Luneheon:      Creamed   chipped   beef,   potato,   fried   mush    and   maple   syrup,   tea, 

milk. 
Dinner:  Soup,  New  England  boiled  dinner,  apple  pie  and  cheese,  coffee. 

Breakfast:     Oatmeal  and  cream,  broiled  steak,  potato,  rolls,  toast,  coffee,  cocoa. 
Luncheon:      Cold  corned  beef,  horseradish  sauce,  potato,  dates,  tea,  milk. 
Dinner:  Soup,  beef  a  la  mode,  potato,  stewed  tomato,  strawberry  ice-cream, 

cake,  coffee. 
Breakfast:     Oatmeal   and   cream,    liver   and   bacon,    potato,    rolls,    toast,    coffee, 

cocoa. 
Luncheon:      Cold  meat  in  brown  sauce,  potato,  boiled  rice  with  cream  or  maple 

syrup,  tea,  milk. 
Dinner:  Soup,  roast  lamb,  mint  sauce,  potato,  string-beans,  chocolate  pud- 

ding, coffee. 
Breakfast :     Oatmeal  and  cream,  broiled  steak,  potato,  rolls,  toast,  coffee,  cocoa. 
Luncheon:      Cold  lamb,  pickles,  potato,  apple  sauce,  hot  muffins,  tea,  milk. 
Dinner:  Soup,  beef  pie,  potato,  mashed  turnips,  rice  pudding,  coffee. 

Breakfast :     Oatmeal  and  cream,  scrambled  eggs  and  bacon,  potato,  rolls,  toast, 

coffee,  cocoa. 
Luncheon:      Clam  chowder,  ginger-bread  and  cheese,  tea,  milk. 
Dinner:  Soup,   Finnan  haddock,  potato,  macaroni  and   cheese,   beet  pickles, 

bisque  ice-cream,  cake,  coffee. 
Breakfast:     Oatmeal  and  cream.  Hamburger   steak,   potato,   rolls,  toast,  coffee, 

cocoa. 
Luncheon:      Cold  meat  in  tomato  sauce,  potato,  bananas,  tea,  milk. 
Dinner:  Soup,    roast-beef,    apple    sauce,    potato,    green    peas,    New    England 

pudding,  coffee. 
Breakfast:     Wheat  gem  and  cream,  baked  beans,  fish-balls,  brown  bread,  toast, 

coffee,  cocoa. 
Luncheon:      Oyster  stew,  cold  meat,  fruit- jelly,  tea,  milk. 
Dinner:  Soup,    roast-beef,    potato,    squash,    steamed    date    pudding,    lemon 

sauce,  coffee. 
Breakfast:     Oatmeal  and  cream,  broiled  fish,  potato,  rolls,  toast,  coffee,  cocoa. 
Luncheon:      Cold  meat,  potato,  baked  apples,  tea,  milk. 
Dinner:  Soup,  roast  lamb,  mint  sauce,  potato,  boiled  beets,  tapioca  cream, 

coffee. 


HOSPITAL  DIETARIES 


751 


Servants'  Dining  Room. 

Breakfast :  Oatmeal  and  milk,  broiled  ham,  potato,  rolls,  coffee,  tea. 

Dinner:  Braised  beef,  potato,  liot  slaw,  baked  date  pudding. 

Supper:  Cold  meat,  peach  sauce,  tea. 

Breakfast :  Oatmeal  and  milk,  creamed  fresh  fish,  potato,  rolls,  coffee,  tea. 

Dinner:  Soup,  beef -stew  with  dumplings,  potato,  stewed  tomato,  caramel  ice- 
cream. 

Supper:  Cold  meat,  apple  sauce,  tea. 

Breakfast:  Wheat  gems  and  milk,  baked  beans,  fish-balls,  brown  bread,  coffee, 
tea. 

Dinner:  Roast-beef,  potato,  squash,  steamed  molasses  pudding. 

Supper:  Cold  meat,  apjjle  sauce,  tea. 

Breakfast :  Oatmeal  and  milk,  creamed  fresh  fish,  potato,  rolls,  coffee,  tea. 

Dinner:  Soup,  New  England  boiled  dinner,  date  pudding. 

Supper:  Cold  meat,  prune  sauce,  tea. 

Breakfast:  Oatmeal  and  milk,  broiled  steak,  potato,  rolls,  coffee,  tea. 

Dinner:  Beef  a  la  mode,  potato,  stewed  tomato,  dates. 

Supper:  Cold  meat,  peach  sauce,  tea. 

Breakfast :  Oatmeal  and  milk,  liver  and  bacon,  potato,  rolls,  coffee,  tea. 

Dinner:  Soup,  roast  lamb,  potato,  boiled  onions,  strawberry  ice-cream. 
Cold  meat,  apple  sauce,  tea. 

Breakfast :  Oatmeal  and  milk,  creamed  chipped  beef,  potato,  rolls,  coffee,  tea. 

Dinner:  Beef  pie,  potato,  mashed  turnips,  bread  pudding. 

Supper:  Cold  meat,  apple  sauce,  tea. 

Breakfast:  Oatmeal  and  milk,  creamed  salt  fish,  potato,  rolls,  coffee,  tea. 

Dinner:  Soup,  clam  chowder,  potato,  baked  macaroni,  apple  brown  betty. 

Supper:  Cold  meat,  prune  sauce,  tea. 

Breakfast :  Oatmeal  and  milk.  Hamburger  steak,  potato,  rolls,  coffee,  tea. 

Dinner:  Soup,  New  England  boiled  dinner,  bread  pudding. 

Supper:  Cold  meat,  hot  biscuits,  peach  sauce,  tea. 

Breakfast :  Wheat  gems  and  milk,  baked  beans,  fish-balls,  brown  bread,  coffee, 
tea. 

Dinner:  Roast-beef,  potato,  squash,  steamed  date  pudding,  lemon  sauce. 

Supper:  Cold  meat,  apple  sauce. 

Breakfast:  Oatmeal  and  milk,  broiled  fish,  potato,  rolls,  coffee,  tea. 

Dinner:  Soup,  roast  lamb,  potato,  boiled  onions,  New  England  pudding. 

Supper:  Cold  meat,  tea. 

House  Diet 

Breakfast :  Oatmeal  and  milk,  creamed  fish,  potato,  coffee,  tea. 

Dinner:  Soup,  lamb-stew,  potato,  creamed  cabbage,  baked  date  pudding,  tea. 

Supper:  Malt  breakfast  food,  peach  sauce,  tea,  cocoa. 

Breakfast :  Oatmeal  and  milk,  hash,  coffee,  tea. 

Dinner:  Soup,  roast- beef,  potato,  stewed  tomato,  caramel  ice-cream. 

Supper:  Corn-starch,  blanc-mange,  apple  sauce,  tea,  cocoa. 

Breakfast :  Wheat  gem  and  milk,  baked  beans,  brown  bread,  coffee,  tea. 

Dinner:  Soup,  roast-beef,  potato,  squash,  prune  jelly,  tea. 

Supper:  Corn-starch,  blancmange,  apple  sauce,  tea,  cocoa. 

Breakfast:  Oatmeal  and  milk,  scrambled  eggs,  potato,  coffee,  tea. 

Dinner:  Soup,  roast-beef,  potato,  boiled  carrots,  date  pudding,  tea. 

Supper:  Hominy,  prune  sauce,  tea,  cocoa. 

Breakfast :  Oatmeal  and  milk,  creamed  fresh  fish,  potato,  coffee,  tea. 

Dinner:  Soup,  lamb-stew,  potato,  stewed  tomato,  dates,  tea. 

Supper:  Farina,  peach  sauce,  tea,  cocoa. 

Breakfast :  Oatmeal  and  milk,  hash,  coffee,  tea. 

Dinner:  Soup,  roast  lamb,  potato,  boiled  onions,  strawberry  ice-cream,  tea. 

Supper:  Cerealine,  apple  sauce,  tea,  cocoa. 

Breakfast:  Oatmeal  and  milk,  broiled  minced  beef,  potato,   coffee,  tea. 

Dinner:  Soup,  roast-beef,  potato,  mashed  turnip,  bread  pudding,  tea. 

Supper:  Malt  breakfast  food,  sauce,  tea,  cocoa. 

Breakfast :  Oatmeal  and  milk,  creamed  salt  fish,  potato,  coffee,  tea. 

Dinner:  Soup,  baked  fish,  potato,  baked  macaroni,  apple  brown  betty. 

Supper:  Irish  moss,  blanc-mange,  prune  sauce,  tea,  cocoa. 


752 


DIETARIES  IN  PUBLIC  INSTITUTIONS 


Breakfast:  Oatmeal  and  milk,  hash,  coffee,  tea. 

Dinner:  Soup,  roast-beef,  potato,  boiled  beets,  vanilla  ice-cream,  tea. 

Supper:  Hominy,  peach  sauce,  tea,  cocoa. 

Breakfast:  Wheat  gem  and  milk,  baked  beans,  brown  bread,  coffee,  tea. 

Dinner:  Soup,  roast-beef,  potato,  squash,  prune  jelly,  tea. 

Supper:  Farina,  apple  sauce,  tea,  cocoa. 

Breakfast :  Oatmeal  and  milk,  scrambled  eggs,  potato,  coffee,  tea. 

Dinner:  Soup,  roast  lamb,  potato,  boiled  onions,  New  England  pudding,  tea. 

Supper:  Cerealine,  prune  sauce,  tea,  cocoa. 

FULL  DIET-TABLE— NAVY  HOSPITALS 

The  following  diet  will  be  observed  for  patients  in  hospital  when 
practicable,  proper  restrictions  being  ordered,  or  a  special  diet  pre- 
scribed, by  the  medical  officer  in  charge  of  the  ward,  in  any  case 
requiring  it: 


Sunday : 

Breakfast : 


Dinner : 


Supper: 


Monday : 

Breakfast : 


Dinner : 
Supper: 


Tuesday : 

Breakfast : 


Dinner : 


Supper: 


Wednesday  : 
Breakfast : 

Dinner: 


Coffee,  1  ounce;  bread,  4  ounces;  butter,  1  ounce;  milk,  6 
ounces;  sugar,  1  ounce;  oatmeal,  1  ounce;  beefsteak,  6 
ounces. 

Rice  soup,  8  ounces ;  bread,  4  ounces ;  roast-beef  or  roast  or 
boiled  fowl,  8  ounces;  potatoes,  8  ounces;  other  vegetables, 
6  ounces;  pickles,  1  ounce;  bread  pudding  with  sauce  or 
frozen  custard,  8  ounces ;  fresh  fruit,  6  ounces. 

Tea,  i  of  an  ounce;  bread,  6  ounces;  butter,  1  ounce;  milk,  2 
ounces;  sugar,  1  ounce;  cold  roast  mutton  or  cold  roast- 
beef,  4  ounces;  stewed  dried  fruit  or  baked  fresh  fruit  or 
apple  sauce,  4  ounces. 

Coffee,  1  ounce;  bread,  4  ounces;  butter,  1  ounce;  milk,  2 
ounces ;  sugar,  |  of  an  ounce ;  cornmeal  ( bread  or  mush ) , 
2 J  ounces ;  ham  and  eggs  ( 2 )   or  potatoes,  4  ounces ;  sausage, 

3  ounces. 

Sago  soup,  8  ounces ;  bread,  4  ounces ;  roast  mutton  or  lamb  or 
boiled  ham,  8  ounces;  potatoes,  8  ounces;  other  vegetables, 
6  ounces;  pickles,  1  ounce;  pie,  6  ounces. 

Tea,  i  of  an  ounce ;  bread,  6  ounces ;  butter,  1  ounce ;  milk,  2 
ounces;  sugar,  1  ounce;  cold  roast-beef  or  beef-stew  or 
hash,  8  ounces;  cheese,  2  oimces;  baked  fresh  fruit  or 
apple  sauce  or  stewed  dried  fruit,  4  ounces. 

Coffee,  1  ounce;  bread,  4  ounces;  butter,  1  ounce;  milk,  2 
ounces;    sugar,    f   of   an   ounce;    pork,    1    ounce,   and   beans, 

4  ounces,  or   beef-stew   or  hash,   8   ounces,   or   mutton-stew, 
8  ounces. 

Vegetable  soup,  8  ounces;  bread,  4  ounces;  boiled  corned  beef 
or  roast-beef,  8  ounces;  potatoes,  8  ounces;  other  vege- 
tables, 6  ounces;  pickles,  1  ounce;  boiled  or  baked  dump- 
lings with  sauce,  6  ounces. 

Tea,  i  of  an  ounce;  bread,  6  ounces;  butter,  1  ounce;  milk, 
2  ounces;  sugar,  1  ounce;  cold  roast  mutton  or  lamb  or 
cold  ham,  4  ounces;  apple  sauce  or  baked  fresh  fruit  or 
stewed  dried  fruit,  4  ounces. 

Coffee,  1  ounce;  bread,  4  ounces;  butter,  1  ounce;  milk,  6 
ounces;  sugar,  1  ounce;  oatmeal,  1  ounce;  mutton  or  lamb 
chops,  6  ounces,  or  liver,  4  ounces,  and  bacon,  i  an  ounce. 

Macaroni  soup,  8  ounces;  bread,  4  ounces;  roast  veal  or  roast 
or  boiled  fowl,  8  ounces;  potatoes,  8  ounces;  other  vege- 
tables, 6  ounces;  pickles,  1  ounce;  tapioca  pudding  with 
sauce,  6  ounces. 


HOSPITAL  DIETARIES 


753 


Supper: 


Thursday  : 

Breakfast : 


Dinner  : 


Supper 


Friday  : 

Breakfast . 


Dinner: 
Supper: 

Saturday : 

Breakfast . 

Dinner  • 

Supper : 


Tea,  i  of  an  ounce;  bread,  6  ounces;  butter,  1  ounce;  milk, 
2  ounces;  sugar,  1  ounce;  corned-beef  liash,  8  ounces,  or 
cold  roast-beef,  4  ounces;  stewed  dried  fruit  or  baked  fresh 
fruit  or  apple  sauce,  4  ounces. 

Coffee,  1  ounce;  bread,  4  ounces;  butter,  1  ounce;  milk,  2 
ounces;  sugar,  |  of  an  ounce;  beefsteak,  6  ounces;  sugar, 
i  of  an  ounce;  milk,  4  ounces;  oatmeal,  1  ounce,  or  pota- 
toes, 4  ounces. 

Vermicelli  soup,  8  ounces;  bread,  4  ounces;  roast-beef,  8 
ounces,  and  potatoes,  8  ounces,  or  pork,  3  ounces,  and  beans, 
4  ounces;  other  vegetables,  6  ounces;  pickles,  1  ounce;  corn- 
starch pudding  with  sauce,  6  ounces. 

Tea,  i  of  an  ounce;  bread,  6  ounces;  butter,  1  ounce;  milk,  2 
ounces;  sugar,  1  ounce;  cold  veal-stew  or  beef-stew  or  hash, 
8  ounces;  baked  fresh  fruit  or  stewed  dried  fruit  or  apple 
sauce,  4  ounces. 

Coffee,  1  ounce ;  bread,  4  ounces ;  butter.  1  ounce ;  milk,  2 
ounces;  sugar,  J  of  an  ounce;  sugar,  milk,  4  ounces;  oatmeal, 
1  ounce;  mackerel,  4  ounces,  or  hominy,  2  ounces;  codfish,  4 
ounces. 

Bean  soup,  8  ounces;  bread,  4  ounces;  fish,  fresh,  10  ounces, 
or  fish,  salt,  8  ounces;  potatoes,  8  ounces;  other  vegetables, 
6  ounces;  pickles,  1  ounce;  pie,  6  ounces. 

Tea,  l  of  an  ounce;  bread,  6  ounces;  butter,  1  ounce;  milk,  2 
ounces;    sugar,    1    ounce;    macaroni,    2    ounces,    and    cheese, 

1  ounce,  or  cold  roast-beef,  4  ounces,  or  beef-stew  or  hash, 
8  ounces.  Stewed  dried  fruit  or  apple  sauce  or  baked  fresh 
fruit,  4  ounces. 

Coffee,  1  ounce;  bread,  4  ounces;  butter,  1  ounce;  milk,  2 
ounces;  sugar,  f  of  an  ounce;  beef-stew  or  mutton  stew, 
8  ounces. 

Barley  soup,  8  ounces;  bread,  4  ounces;  roast-mutton  or  roast- 
beef,  8  ounces;  potatoes,  8  ounces;  other  vegetables,  6 
ounces;  pickles,  1  ounce;  rice  pudding  with  sauce,  6  ounces. 

Tea,    '}   of   an   ounce;    bread,    6   ounces;    butter,    1    ounce;    milk, 

2  ounces;  sugar,  1  ounce;  dried  chipped  beef,  .3  ounces,  or 
canned  salmon,  4  ounces ;  apple  sauce  or  stewed  dried  fruit 
or  baked  fresh  fruit,  4  ounces. 


The  weights  of  meats  and  vegetables,  including  cereals,  etc.,  are 
those  of  the  articles  as  purchased,  and  this  applies  to  the  table  as  a 
whole,  the  exceptions,  such  as  soups  and  puddings,  being  apparent. 
Whenever  stews  are  indicated,  4  ounces  of  meat  and  an  equal  amount 
of  potatoes  are  allowed  in  their  composition,  with  such  simple  addi- 
tions as  palatableness  may  require.  For  supper  the  cold  meats  pre- 
scribed may  be  made  into  hashes  or  stews  when  it  is  considered  ad- 
visable for  the  sake  of  variety. 

The  item  "bread"  is  considered  to  include  loaf,  rolls,  and  other 
forms,  and  a  reasonable  variety  of  the  best  quality  should  be  pro- 
vided. Syrup  or  honey,  not  to  exceed  1  ounce,  should  be  allowed  at 
breakfast  as  desired.  It  is  assumed  that  the  table  is  provided  at  all 
times  with  vinegar,  salt,  and  the  usual  condiments. 

From  time  to  time,  as  the  season  permits,  fruits  and  berries  may  be 
substituted  for  the  desserts  prescribed,  and  under  the  head  of  "other 
48 


754 


DIETARlJi^S  I]!f  PUBLIC  I^ISTITL  TWIN'S 


vegetables"  provision  for  additional  fresh  food  should  be  made  as  the 
abundance  of  the  market  permits. 

The  foregoing  table  shall  be  observed  for  employees. 

I.     ORDINARY  DIET    TABLE— UNITED    STATES   MARINE   HOSPITALS 


Suif DAY : 

Breakfast . 

Dinner : 

Supper : 

Monday  : 

Breakfast : 

Dinner : 

Supper : 

Tuesday : 

Breakfast: 

Dinner : 

Slipper  : 

Wed>t;sday  : 
Breakfast : 

Dinner : 

Supper : 

Thtjesday  : 

Breakfast: 

Dinner : 

Friday  : 

Breakfast : 

Dinner : 

Supper: 

Satueday : 

Breakfast : 

Dinner : 

The  tea  and 


Chocolate,  1  pint:  bread,  6  ounces;  butter,  i  of  an  ounce;  meat- 
stew,  4  ounces;  fruit  sauce,  3  ounces. 

Soup,  1  pint;  roast-beef,  6  ounces;  potatoes,  8  ounces;  other 
vegetables,  4  ounces;  rice  or  tapioca  pudding,  4  ounces. 

Tea,  1  pint;  bread,  6  ounces;  butter,  |  of  an  ounce;  mush  and 
milk,  12  ounces. 

Coffee,   1  pint;   bread,  6  ounces;   butter,  i  of  an  ounce;   meat- 
hash  with  vegetables,  6  ounces;  stewed  fruit,  3  ounces. 
Vegetable   soup,    1    pint;    beef    (boiled),   6   ounces;    potatoes,   8 

ounces;  pudding  with  sauce,  4  ounces;  bread,  4  ounces. 
Tea,  1  pint;  bread,  6  ounces;  butter,  ^  of  an  ounce;  fruit  sauce, 

3  ounces. 

Coffee,  1  pint;  bread,  6  ounces;  butter,  i  of  an  ounce;  corned- 
beef  hash  with  potatoes,  6  ounces. 

Beef  soup,  1  pint;  beef  (boiled),  6  ounces;  fish,  fresh,  6  ounces; 
vegetables,  8  ounces;   bread,  4  ounces;  fruit,  4  ounces. 

Tea,  1  pint;  bread,  6  ounces;  butter,  4  of  an  ounce,  fruit 
(stewed),  4  ounces.  Fresh  fruit  may  be  substituted  in 
season. 

Coffee,    1    pint;    bread,    4    ounces;    butter,    2    ounces;    fish-hash 

with  vegetables,  6  ounces. 
Mutton  broth,   1   pint;   mutton    (boiled),  6  ounces;   potatoes,  8 

ounces;   rice  pudding  with  sauce,  4  ounces;  bread,  4  ounces. 
Tea,   1   pint;    bread,   6   ounces;    butter,   i   of  an  ounce;    cooked 

fruit,  4  ounces. 

Coffee,  1  pint;  bread,  6  ounces;  butter,  |  of  an  ounce;  meat- 
stew,  6  ounces. 

Soup  (bouillon),  1  pint;  roast-beef,  6  ounces;  potatoes,  8 
ounces;  bread,  4  ounces;  fruit,  4  ounces. 

•     Coffee,   1   pint;    bread,   6   ounces;    butter,   J   of  an  ounce;    fish- 
hash  with  vegetables,  6  ounces. 
Vegetable   soup,    1    pint;    meat-stew,   8   ounces;    fish,   6   ounces; 

bread,  4  ounces;  vegetables,  8  ounces;  fruit,  4  ounces. 
Tea,  1  pint;  bread,  4  ounces;  butter,  |  of  an  ounce;  cold  meat, 

4  ounces. 

■     Coffee,  1  pint;   bread  6  ounces;   butter,  ^  of  an  ounce;   mutton 

chop,  6  ounces;  fried  potatoes,  3  ounces. 
Barley    soup,    1    pint;    mutton     (boiled),    8    ounces;    bread,    4 

ounces;   vegetables,  10  ounces, 
coffee  prepared  with  milk  and  sugar. 


Breakfast : 
Dinner : 
Supper : 


Breakfast : 


II.  Extra  Diet 
Mutton  chop  or  beefsteak,  6  ounces;  eggs,  2. 
Chicken  or  game,  6  ounces;  ale  or  wine. 
Dry  or  dip  toast,  4  ounces. 

III.  Milk  Diet 

Hominy  or  corn-meal  mush,  14  ovmces;  milk,  16  ounces. 


HOSPITAL  DIETARIES 


755 


Dinner:  Rice  or  tapioca    (cooked),    12   ounces;    milk,    16   ounces;    syrup,    1 

ounce;  bread,  4  ounces;  butter,  i  of  an  ounce. 

Supper:  Cracked   wheat   or   oaten-grits    (when   cooked),    14    ounces;    toasted 

bread,  12  ounces;  milk,  16  ounces. 


ALLOWANCE  AND  COST  OF  OUTLAY  AT  CRAIG  EPILEPTIC  COLONY, 

NEW  YORK 


Articles. 

Present  weekly 
per  capita 
allowance. 

Proposed  change 
in  amount. 

Present 

weekly 

per  capita 

cost. 

Proposed 

change  ia 

cost. 

Meat,  etc 

Flour 

Potatoes 

Milk 

Eggs 

Sugar 

Butter 

Cheese 

Sago,  tapioca,  rice   . 

Oatmeal 

Coffee 

Tea 

Vegetables    .... 

3.93  pounds 
5.40       " 
5.20       " 

2.78      " 

5.04  eggs 

15.50  ounces 

11.25       " 

2.00       " 
2.60       " 
4.90       " 
2.70       " 

1.14       " 

(?) 

/  Increase  to  "1 
\  3|  quarts  / 
(  Increase  to ) 
1      6  eggs      i 

f  Increase  to  \ 
\  12  ounces  j 

r  Decrease     \ 
L  to  1  ounce  j 

0.31280 
0.10422 
0.05200 

0.07643 

0.07560 

0.04550 

0.15412 

0.01375 
0.00800 
0.00800 
0.01800 

0.01800 

0.10000 

0.09625 
0.09000 

0.16602 
0.01620 

Part  of  the  provisions  are  from  the  colony  farm. 

Dietary  of  the  Craig  Colony  of  Epileptics,  New  York 
Sunday : 

Breakfast :     Eggs,  coffee,  bread,  butter. 

Dinner:  Soup,  roast-beef,  vegetables,  corn-starch  pudding,  custard  sauce, 

bread. 
Tea,  cookies,  apple  sauce,  bread,  butter. 


Supper: 

Monday : 

Breakfast : 

Dinner: 

Supper: 

Tuesday : 

Breakfast : 
Dinner : 
Supper : 

Wednesday  : 
Breakfast : 
Dinner : 
Supper : 

Thursday: 

Breakfast : 
Dinner : 

Friday  : 

Breakfast : 
Dinner : 

Supper: 
Saturday : 

Breakfast : 
Dinner : 
Supper: 


Rolled  oats,  coffee,  bread,  butter. 

Soup,  mutton,  potatoes,  rice  pudding,  bread. 

Eggs  or  baked  potatoes,  tea,  prunes,  bread,  butter. 

Stewed  potatoes,  coffee,  bread,  butter. 

Meat-stew,  potatoes,  vegetables,  sago  pudding,  bread. 

Corn  bread  or  mush  with  syrup,  tea,  bread,  butter,  apple  sauce. 

Rolled  oats,  coffee,  bread,  butter. 

Soup,  roast-beef,  mashed  potatoes,  vegetables,  bread. 

Boiled  rice,  crackers,  cheese,  tea,  butter. 

Eggs,  coffee,  bread,  butter. 

Soup,  beef-hash,  boiled  potatoes,  bread  pudding,  bread. 

Rolled  oats,  coffee,  bread,  butter. 

Soup,   fresh   fish    (baked),   or   cod-fish,   boiled   potatoes,    stewed 

tomatoes,  gelatin  pudding,  bread. 
Macaroni  and  cheese,  tea,  bread,  butter,  dried  peaches. 

Stewed  potatoes,  eggs,  coffee,  bread,  butter. 

Irish  stew,  apple  sauce,  bread. 

Hot  corn  bread,  tea,  baked  potatoes,  dried  peaches,  butter. 


756  DIETARIES  IN  PUBLIC  INISTITUTIONS 

The  following  vegetables  to  be  used:  Potatoes,  beets,  beans,  peas, 
parsnips,  celery,  onions,  corn,  spinach,  carrots,  tomatoes,  oyster  plant. 
In  case  of  emergency,  the  cook  may  substitute  one  article  of  diet  for 
another,  subject  to  the  approval  of  the  matron,  physician,  steward,  or 
supervisor  in  charge  of  the  division. 

DIET  FOR  CHORISTER  BOYS  IN  SAINT  PAUL'S  SCHOOL,  BALTIMORE 

Breakfast:  Fruit,  cereals,  eggs,  bread  and  milk.     Hot  bread  occa- 

sionally. 

Dinner — Middle  of  day :     Soup,  meat,  gravies  very  carefully  made ;  .three  or  four 

vegetables,  especially  rice  and  potatoes;   custards 
and  simple  plain  desserts. 

Supper:  Bread  and  milk,  hot  cakes,  molasses,  eggs  occasionally; 

preserves,  sweets,  fruit. 
"We  count  milk  as  the  most  important  article  of  diet.     No  coffee  or  tea  at  any 

time.     Gravies  well  made  have  been  found  very  healthful.     Meat  once  a  day  only 

at  dinner.     Eggs  once  a  day,  occasionally  at  supper.     Nuts  absolutely  forbidden." 

DIET  LIST,  TUBERCULOSIS  INFIRMARY,  METROPOLITAN  HOSPITAL, 
BLACKWELL'S  ISLAND 

(All  quantities  are  of  cooked  food,  ready  to  serve.) 
Regular  Diet: 

Breakfast:  Cereal,  8  ounces,  with  milk,  4  ounces;   bread,  4  ounces; 

butter,  i  ounce;  coffee,  16  ounces. 

10  A.  M. :  ^ESy  1  raw,  with  milk,  8  ounces. 

11  A.M.:  Cod-liver  oil  emulsion. 

Dinner  12  noon:     Soup,  12  ounces;   meat,  5  to  7  ounces,  or  fish,  8  ounces; 

potatoes,    8    ovmces;     bread,    4    ounces;    pudding,    6 

ounces. 
3  p.  M. :  Egg,  1  raw,  with  milk,  8  ounces. 

4.30  P.M.:  Cod-liver  oil  emulsion. 

Supper:  Fruit-sauce,  8  ounces;   bread,  4  ounces;   butter,  J  ounce; 

tea,  16  ounces. 
8  P.  M. :  Milk,  8  ounces. 

Speciai,  Diet  (for  bed  patients  especially)  : 
Breakfast:  Same  as  regular  diet. 

Dinner:  Steak,  4  to  6  ounces;  potatoes,  8  ounces;  egg,  1  raw,  with 

milk,  4  ounces ;   pudding,  6  ounces. 
Supper:  Same  as  regular  diet. 

Daily  maximum  allowance  of  milk,  32  ounces. 
Light  Diet: 

Breakfast:  Cereal,  8  ounces;  egg,  1  raw,  with  milk,  4  ounces;  toast 

and  milk. 
Dinner:  Same  as  breakfast. 

Supper:  Same   as    breakfast,    with    lemon-jelly    or    boiled    rice    or 

farina  pudding  replacing  cereal. 
Daily  maximum  allowance  of  milk,  48  ounces. 
Liquid  Diet: 
Boiled  milk. 

Albumin-water,  ad  libitum. 
Broths. 

Scorched  farinaceous  food. 
Daily  maximum  of  milk,  48  ounces. 

REGULAR  DIET  FOR  TUBERCULOSIS  INFIRMARY 

All  quantities  are  of  cooked  food,  as  served. 
Sunday : 

Breakfast:     Hominy,  8  ounces;  with  milk,  4  ounces;  bread,  4  ounces;  but- 
ter, i  ounce;  coffee,  16  ounces. 


HOSPITAL  DIETARIES 


757 


Dinner:  Barley  soup,  12  ounces;  roast-beef,  5  ounces;  potatoes,  8  ounces; 

bread,  -4  ounces;   corn-starch  pudding,  U  ounces. 
Supper:  Stewed   prunes,   8    ounces;    bread,   i    ounces;    butter,    i    ounce; 

tea,  10  ounces. 
Monday  : 

Breakfast:     Oatmeal,  8  ounces;   milk,  4  ounces;   bread,  4  ounces;   butter,  i 

ounce;  coffee,  16  ounces. 
Dinner:  Vegetable  soup,   12   ounces;   corned   beef,  7   ounces;   potatoes,  9 

ounces;  bread,  4  ounces;  bread  pudding',  G  ounces. 
Supper:  Apple  sauce,  8  ounces;    bread,  4  ounces;    butter,  i  ounce;   tea, 

16  ounces. 

TUKSUAV  : 

Breakfast : 

Dinner : 

Supper: 

Wednesday  : 
Breakfast : 

Dinner: 


Supper: 

Thursday  : 

Breakfast : 

Dinner : 

Supper: 

Friday  : 

Breakfast : 

Dinner : 

Supper : 

Saturday : 

Breakfast : 

Dinner: 

Supper : 


Hominy,  8  ounces;   milk,  4  ounces;   bread,  4  ounces;   butter,  i 

ounce;  coffee,  16  ounces. 
Fish   chowder,    14  ounces;    bread,  4   ounces;    coffee,    16   ounces; 

rice  pudding,  6  ounces. 
Pea    or    lentil    soup,    12    ounces;    crackers,    4    ounces;    tea,    16 

ounces;  bread  and  butter. 

Rolled  wheat,  8  ounces;  milk,  4  ounces;  bread,  4  ounces;  but- 
ter, i  ounce;  coffee,  16  ounces. 

Pot-roast-beef,  or  chopped  roast-beef,  5  ounces;  gravy;  potatoes, 
8  ounces;  one  vegetable,  4  ounces;  bread,  4  ounces;  farina 
pudding,  6  ounces. 

Stewed  prunes,  8  ounces;  bread,  8  ounces;  butter,  J  ounce; 
tea,  16' ounces. 

Indian  meal,  8  ounces;  milk,  4  ounces;  bread,  4  ounces;  but- 
ter, J  ounce;  coffee,  16  ounces. 

Boiled  mutton,  4  ounces;  with  broth,  8  ounces;  bean  polenta  or 
lentils,  8  ounces;  bread,  4  ounces;  cracker  pudding,  6  ounces. 

Boiled  rice,  6  ounces;  with  milk,  4  ounces;  bread,  4  ounces; 
butter,  J  ounce;  tea,  16  ounces. 

Oatmeal,   8   ounces;    milk,   4   ounces;    bread,   4   ounces;    butter, 

i  ounce;  coffee,  16  ounces. 
Fresh    fish,    6    ounces;    potatoes,    8    ounces;    bread,    4    ounces; 

hominy  pudding,  6  ounces;  tea,  IG  ounces. 
Apple  sauce,  8  ounces;   bread,  8  ounces;   butter,  i  ounce;   tea, 

16  ounces. 

Rolled    wheat,    8    ounces;    milk,    4    ounces;    bread,    4    ounces; 

butter,  J  ounce;  coffee,  16  ounces. 
Beef-stew%  16  ounces    (potato  in  stew)  ;   bread,  4  ounces;  farina 

pudding,  6  ounces. 
Farina  pudding,  6  ounces;  with  milk,  4  ounces;  bread,  4  ounces; 

butter,  \  ounce;  tea,  16  ounces. 


Egg,  1  raw,  with  milk,  8  ounces. 
Cod-liver  oil  emulsion,  as  directed. 


10  A.  M. :  1 
3  P.  M. :  |Daily 

11  A.  m.:1d_^ily 
4.30  P.M.:  J 

8  P.  M. :     Daily  :     ISIilk,  8  ounces. 

DIETARY  OF  THE  SECOND  HOSPITAL  FOR  THE  INSANE  OF  MARYLAND  FOR 

THE  MONTH  OF  APRIL 
Sunday  : 

Breakfast :     Steak,  gravy,  grits,  bread,  syrup,  coffee. 
Dinner:  Beef  gravy,  baked  beans,  parsnips,  bread,  dessert. 

Supper:  Roasted  potatoes,  cheese,  crackers,  ginger  cakes,  bread,  syrup, 

tea. 
Monday : 

Breakfast:    Beefsteak,  grits,  bread,  syrup,  and  coffee. 


758 


DIETARIES  IN  PUBLIC  INSTITUTIOMS 


Dinner : 
Supper : 

Tuesday : 

Breakfast : 
Dinner : 
Supper : 

Wednesday  : 
Breakfast : 
Dinner : 
Supper  : 

Thursday  : 

Breakfast  : 
Dinner  : 
Supper : 

Friday  : 

Breakfast : 
Dinner: 
Supper : 

Saturday : 

Breakfast : 
Dinner : 
Supper : 


Soup,  greens,  potatoes,  hominy,  and  bread. 
Stewed  prunes,  bread,  syrup,  and  tea. 

Oatmeal,  meat-stew,  bread,  syrup,  and  coffee. 
Salt  meat,  parsnips,  greens,  beans,  and  bread. 
Stewed  apples,  bread,  syrup,  butter,  and  tea. 

Meat-stew,  potatoes,  bread,  syrup,  coffee. 
Soup,  beef,  gravy,  turnips,  onions,  bread. 
Stewed  prunes,  bread,  syrup,  tea. 

Smoked  sausage,  grits,  bread,  syrup,  coffee. 
Salt  meat,  potatoes,  greens,  hominy,  bread. 
Ginger-bread,  bread,  syrup,  butter,  tea. 

Salt  or  fresh  fish,  potatoes,  bread,  syrup,  coffee. 
Fresh  fish,  baked  beans,  turnips,  parsnips,  bread. 
Hominy,  cheese,  crackers,  bread,  syrup,  tea. 

Oatmeal,  meat-stew,  bread,  syrup,  coffee. 
Soup,  greens,  potatoes,  onions,  bread. 
Fried  musli,  bread,  syrup,  butter,  tea. 


UNITED  STATES  GOVERNMENT  HOSPITAL  FOR  THE  INSANE, 
WASHINGTON,  D.  C. 


Sunday : 

Breakfast . 
Dinner  : 
Supper : 

Monday : 

Breakfast : 
Dinner: 
Supper : 

Tuesday : 

Breakfast : 
Dinner : 

Supper : 
Wednesday  : 
Breakfast : 
Dinner: 

Supper : 

Thursday  : 

Breakfast : 
Dinner: 
Supper : 

Friday  : 

Breakfast : 
Dinner: 
Supper : 

Saturday : 

Breakfast : 
Dinner : 
Supper: 

Sunday  : 

Breakfast : 
Dinner : 

Supper : 


Dietary  for  Patient  on  the  Sick  List 

Cereal,  mackerel,  creamed  potatoes,  coffee,  toast. 
Tomato  bisque,  lamb  stew,  peas,  bread,  pudding. 
Shredded  wheat,  sliced  bananas,  tea. 

Cereal,  hash,  coffee,  toast. 

Corn  soup,  pot-roast-beef,  rice,  parsnips,  cherry  ice-cream. 

Creamed  salmon,  toast,  tea. 

Oatmeal,  Ijeefsteak,  baked  potatoes,  coffee,  toast. 

Vegetable   soup,   potatoes,   beef-loaf,  tomato  sauce,  junket  with 

fruit. 
Cream  toast,  tea,  apple  sauce. 

Wheatlet,  bacon,  creamed  potatoes,  zwieback,  coffee. 

Oyster    stew,    fricasseed   chicken,   rice,    browned   parsnips,   wine 

jelly,  custard  sauce. 
Shredded  wheat,  hot  milk,  sliced  fruit. 

Cereal,  steak,  potatoes,  coffee. 

Potato  soup,  beef-stew,  rice,  turnips,  cottage  pudding. 

Egg,  toast,  tea. 

Cereal,  mackerel,  creamed  potatoes,  coffee,  rolls. 
Bean  soup,  veal  stew,  tomatoes,  ice-cream. 
Raw  oysters,  apple  sauce,  tea. 

Cereal,  eggs,  potatoes,  toast,  coffee. 

Oyster  stew,  roasted  veal,  tomatoes,  rice,  custard. 

Broiled  shad,  toast,  tea. 

Dietary  for  Better  Class  of  Patients 

Wheatlet,  ham,  creamed  potatoes,  corn  bread. 

Vegetable    soup,    fricasseed    chicken,    toast,    tomatoes,    potatoes, 

Spanish  cream,  sauce. 
Cold  ham,  potato  cakes,  sauce,  cake. 


HOSPITAL  DIETARIES 


759 


Monday  : 

Breakfast . 
Dinner : 

Supper : 
Tuesday : 

Breakfast : 
Dinner : 

Supper  : 

Wednesday  : 
Breakfast  : 
Dinner : 

Supper : 
Thursday  : 

Breakfast : 
Dinner : 

Supper: 
Friday  : 

Breakfast : 
Dinner: 

Supper : 
Saturday : 

Breakfast : 
Dinner : 
Supper : 


Rolled  oats,  steak,  onions,  potatoes,  batter  cakes. 

Potato    soup,    beef-stew     (baked),    parsnips,    potatoes,    baked 

custard. 
Sausage  cakes,  scalloped  potatoes,  apple  sauce. 

Breakfast  food,   lamb  cliops,_  potatoes,   muffins. 

Tomato  bisque,  roast  pork,  apple  sauce,  boiled  onions,  potatoes, 
tapioca  pudding. 

Cold  tongue,  French-fried  potatoes,  evaporated  peaclies,  dough- 
nuts. 

Rolled  oats,  bacon,  eggs,  potatoes,  corn  bread. 

Vegetable    soup,    fish,    beef     (roast),    turnips,    potatoes,    frozen 

custard. 
Beef  croquettes,  potato  salad,  cream-puflfs. 

Corn-meal  mush,  steak,  potatoes,  batter  cakes. 

Vegetable    soup,    ham,    kale,    potatoes,    chocolate    blanc-mange, 

sauce. 
Sliced  beef,  potatoes,  hot  biscuits. 

Rolled  oats,  fresh  fish,  potatoes,  muffins. 

Tomato   bisque,   oyster   pie,   roast-beef,   corn,   potatoes,    floating 

island. 
Scraml)led  eggs,  French-fried  potatoes,  apple  sauce. 

Rolled  oats,  steak,  potatoes,  fried  mush. 

Clear  soup,  roast-beef,  macaroni,  potatoes,  lemon  ice. 

Fish  croquettes,  fried  potatoes,  evaporated  peaches. 


V.  S.  GOVERNMENT  HOSPITAL  FOR  THE  INSANE, 
ST.  ELIZABETH,  D.  C. 


Sunday : 

Breakfast ; 

Dinner : 
Supper  : 
Monday : 

Breakfast : 
Dinner : 
Supper: 

Tuesday  : 

Breakfast : 

Dinner : 
Supper : 

Wednesday  : 
Breakfast : 

Dinner  : 
Supper : 

Thursday  : 

Breakfast : 

Dinner : 
Supper : 


For  the  Month  of  October. 

Wheatlet,    baked    beans,    rolls.     For    employees    and    working 

patients,  fried  ham. 
Roast-beef,  bread  dressing,  tomatoes,  potatoes,  dessert,  cofiee. 
Evaporated  fruit,  cake. 

Fresh  sausage,  fried  hominy,  rolls. 
Boiled  shoulders,  pea  soup,  boiled  rice,  cabbage. 
Apple  jelly,  rolls.     For  employees  and  working  patients,  dried 
beef. 

Pettijohn's  food,  liver  and  bacon,  rolls. 
Vegetable  soup,  beef-stew,  lima  beans,  dessert. 
Evaporated  fruit,  cinnamon  bread.     For  employees  and  working 
patients,  cold  sliced  shoulders. 

Rolled   oats,    baked   hash,    rolls.     For    employees    and    working 

patients,  beefsteak. 
Bean  soup,  corned  beef,  boiled  rice,  cabbage. 
Ginger-bread,  apple  sauce.     For  employees  and  working  patients, 

bologna  sausage. 

Corn-meal   mush,   evaporated   fruit,    rolls.     For   employees   and 

working  patients,  mutton  chops. 
Vegetable  soup,  beef  pot-pie,  cabbage,  kidney  beans. 
Baked   beans,   biscuits.     For   employees   and   working   patients, 

sliced  corned  beef. 


760 


DIETARIES  IN  PUBLIC  INSTITUTIONS 


Fbiday  : 

Breakfast : 
Dinner : 
Supper : 

Saturday : 

Breakfast  : 
Dinner : 
Supper : 


Mackerel  or  cod-fish,  potatoes,  rolls. 

Fresh  fish,  macaroni,  boiled  rice,  pickles,  apple  or  peach  pie,  coffee. 
Evaporated  fruit,  crackers,  cheese.     For  employees  and  working 
patients,  fresh  fish. 

Beefsteak,  fried  hominy. 

Vegetable  soup,  boiled  beef,  boiled  cabbage,  potatoes. 
Evaporated    fruit,    fresh    bread,    ginger    cakes.     For    employees 
and  working  patients,  cold  sliced  beef. 

For  the  Month  of  July. 

Wheatlet,    baked    beans,    rolls.     For    employees    and    working 

patients,  fried  ham. 
Roast-beef,  bread  dressing,  tomatoes,  potatoes,  dessert,  coffee. 
Evaporated  fruit,  cake. 

Smoked     sausage,    fried    hominy,     rolls.     For    employees    and 

working  patients,  fried  eggs. 
Boiled  shoulder,  pea  soup,  boiled  rice,  cabbage. 
Apple  jelly,  rolls.     For  employees  and  working  patients,  dried 

beef. 

Pettijohn's  food,  liver  and  bacon,  rolls. 

Vegetable  soup,  beefstew,  lima  beans,  dessert.  For  employees 
and  working  patients,  roast  mutton. 

Evaporated  fruit,  cinnamon  bread.  For  employees  and  work- 
ing patients,  cold  sliced  shoulders. 

Rolled    oats,    baked    hash,    rolls.     For    employees    and    working 

patients,  veal  cutlets. 
Bean  soup,  corned  beef,  macaroni,  browned  potatoes. 
Ginger-bread,  apple  sauce.     For  ejnployees  and  working  patients, 

fish-balls. 

Corn-meal  mush,   evaporated   fruit,   rolls.     For   employees   and 

working  patients,  mutton  chops. 
Vegetable  soup,  veal  pot-pie,  cabbage,  kidney  beans. 
Baked    beans,   biscuits.     For   employees   and   working   patients, 

sliced  corned  beef. 

Mackerel  or  cod-fish,  potatoes,  rolls. 

Fresh  fish,  macaroni,  boiled  rice,  pickles,  apple  or  peach  pie. 
Evaporated   frviit,   crackers,   cheese.     For   employees   and   work- 
ing patients,  fried  eggs. 

Beefsteak,  fried  hominy. 

Vegetable  soup,  boiled  beef,  boiled  cabbage,  potatoes. 
Evaporated    fruit,    fresh    bread,    ginger    cakes.     For    employees 
and  working  patients,  breakfast  bacon. 

Butter  should  be  on  the  table  at  every  meal,  except  meals  with 
soup,  in  proportion  of  y^  ounce  to  each  person. 

Bread  supplied  as  desired. 

Coffee,  1/2  ounce  per  capita  for  breakfast  and  dinner;  tea,  %o  ounce 
per  capita,  for  supper. 

Syrup  should  be  on  the  table  for  breakfast  and  supper  every  day. 

Crackers  should  be  on  the  table  for  dinner  every  soup-day,  to  be 
used  as  desired. 


Sunday  : 

Breakfast : 

Dinner : 
Supper: 
Monday : 

Breakfast : 

Dinner  : 
Supper: 

Tuesday: 

Breakfast : 
Dinner  : 

Supper : 

Wednesday  : 
Breakfast : 

Dinner: 

Supper : 

Thursday  : 

Breakfast : 

Dinner : 
Supper: 

FEn)AY : 

Breakfast : 
Dinner : 
Supper : 

Saturday : 

Breakfast : 
Dinner : 
Supper : 


HOSPITAL  DIETARIES 


761 


All  bones  from  meat,  cut  out  before  or  after  cooking,  should  be 
preserved  and  used  in  the  soup  if  necessary. 

Milk  and  sugar  are  to  be  used  in  coffee  and  tea  as  desired. 

Extra  diet  is  served  on  the  prescription  of  the  physician  only,  who 
shall  designate  the  special  articles  desired  and  the  quantity. 

Employees'  Dietary 

Rolled  oats,  steak,  potatoes,  corn  bread. 
Vegetable  soup,  shoulder,  kale,  potatoes,  coffee. 
Beef-stew,  evaporated  peaches. 

AVheatlet,  ham,  potatoes,  rolls. 

Vegetable  soup,  roast-beef,  tomatoes,  potatoes,  Spanish  cream, 

coffee. 
Potato  salad. 

Breakfast  food,  bacon,  liver,  baked  potatoes. 
Vegetable  soup,  roast  pork,  rice,  potatoes,  coffee. 
Cold  shoulder,  buckwheat  cakes,  apple  sauce. 

Rolled  oats,  sausage,  fried  hominy,  rolls. 

Bean  soup,  shoulder,  turnips,  potatoes,  cottage  pudding,  sauce, 

coffee. 
Baked  hash,  rhubarb  sauce,  cinnamon  bread. 

Rolled  oats,  fried  eggs,  potatoes,  rolls. 
Vegetable  soup,  fish,  corned  beef,  turnips,  potatoes,  peach  pie, 

coffee. 
Smoked  fish,  baked  potatoes,  evaporated  peaches. 

Corn-meal  mush,  steak,  potatoes,  rolls. 

Vegetable  soup,  beef -stew    (baked),  parsnips,  potatoes,  coffee. 

Cold  corned-beef,  baked  beans,  rolls. 

Rolled  oats,  fresh  fish,  potatoes,  rolls. 

Vegetable   soup,   baked   fish,   roast-beef,   corn,   potatoes,   floating 

island,  coft'ee. 
Scrambled  eggs,  fried  potatoes. 

FORMER  DIET-LIST  OF  BAY  VIEW  ASYITJM 


Sunday : 

Breakfast. 

Dinner : 

Supper : 
Monday : 

Breakfast . 

Dinner : 

Supper : 

Tuesday : 

Breakfast . 
Dinner : 
Supper: 

Wednesday  : 
Breakfast : 
Dinner : 

Supper: 
Thursday: 

Breakfast : 
Dinner : 

Supper : 

Friday  : 

Breakfast : 
Dinner : 
Supper: 

Saturday : 

Breakfast : 
Dinner : 

Supper: 


This  is  the  almshouse  of  Baltimore.  The  lists  are  given  here  not 
because  they  represent  ideal  diet-lists,  but  merely  to  show  what  the 
average  well-conducted  poor-house  in  this  country  furnishes  its  in- 
mates. In  this  institution  the  inmates  are  well  cared  for,  and  in 
season  the  diet  is  varied  by  vegetables  from  the  farm. 


Sunday  : 

Breakfast : 

Dinner: 

Supper: 

Monday  : 

Breakfast : 
Dinner : 
Supper : 

Tuesday : 

Breakfast : 
Dinner : 


Hospital. 

Oatmeal,  bread,  butter,  eggs,  milk,  tea,  coffee. 

Chicken  soup,  roast-beef  and  gravy,  bread,  tea. 

Bread,  butter,  tea,  cofl'ee,  stewed  apples  or  prunes,  milk. 

Oatmeal,  bread,  butter,  eggs,  milk,  tea,  coffee. 
Beef  soup,  roast-beef  and  gravj,  bread,  tea. 
Bread,  butter,  tea,  coffee,  milk. 

Oatmeal,  bread,  butter,  eggs,  milk,  tea.  coffee. 
Beef  soup,  rice,  milk,  bread,  butter,  tea. 


762 


DIETARIES  IN  PUBLIC  INSTITUTIONS 


Supper  : 

Wednesday  : 
Breakfast  : 
Dinner : 
Supper: 

Thursday  : 

Breakfast : 
Dinner : 
Supper  : 

Friday  : 

Breakfast : 
Dinner  : 
Supper : 

Saturday : 

Breakfast  : 

Dinner: 

Supper: 


Bread,  butter,  tea,  coffee,  milk. 

Oatmeal,  bread,  butter,  milk,  tea,  coffee. 
Chicken  soup,  beefsteak,  apple  sauce,  bread,  tea. 
Bread,  butter,  tea,  coffee,  milk. 

Oatmeal,  bread,  butter,  eggs,  milk,  tea,  coffee. 
Beef  soup,  roast-beef  and  gravy,  bread,  tea. 
Bread,  butter,  tea,  coffee,  milk. 

Bread,  butter,  mush  and  molasses,  eggs,  milk,  tea,  coffee. 
Beef  soup,  rice,  milk,  bread,  butter,  tea. 
Bread,  butter,  tea,  coffee,  milk. 

Oatmeal,  bread,  bvitter,  eggs,  milk,  tea,  coffee. 
Beef  soup,  beefsteak,  bread,  tea,  apple  sauce. 
Bread,  butter,  tea,  coffee,  milk. 


In  addition  to  the  foregroing:,  beef -tea,  lemonade,  and  various  other 
articles  of  diet  are  furnished  from  the  "center-house  kitchen"  when 
necessary.  On  Fridays  in  spring  and  summer,  when  the  cost  is  not 
too  high,  fish  is  given  for  dinner. 


Sunday: 

Breakfast : 

Dinner : 

Supper : 
Monday : 

Dinner: 

Supper : 
Tuesday : 

Dinner : 
Wednesday  : 

Dinner: 
Thursday  : 

Dinner: 
FemAY : 

Dinner: 
Saturday : 

Dinner : 


Sunday : 

Breakfast : 
Dinner : 
Supper : 

Monday : 

Breakfast : 
Dinner: 
Supper : 

Tuesday : 

Breakfast : 
Dinner : 

Wednesday  : 
Breakfast : 
Dinner : 

Thursday  : 
Breakfast : 
Dinner : 


General  House 
(See  note  at  beginning  of  these  lists.) 

Every  day,  bread  and  coffee;    on   Friday,  mush  and  molasses 

are  added. 
Soup,   bacon,    bread. 
Bread,  coffee,  dried  apples  or  prunes. 

Soup,  beef,  bread. 
Bread,  coffee  every  day. 

Hash,  soujj,  bread. 

Hash,  soup,  bread. 

Soup,  beef,  bread.  * 

Mutton  soup,  bread. 

Hash,  soup,  bread. 

For  Working  Women. 

Oatmeal,  milk,  bread,  butter,  coffee,  tea. 

Bacon,  soup,  bread. 

Bread,  coffee,  tea,  stewed  fruit  or  prunes. 

Bread,  butter,  oatmeal,  hash,  coffee,  tea. 

Soup,  beef,  bread. 

Bread,  coffee,  tea  every  day. 

Oatmeal,  Hamburg  steak,  bread,  butter,  coffee,  tea. 
Bacon,  hash,  soup,  rice,  milk,  bread. 

Bread,  butter,  oatmeal,  coffee,  tea. 
Hash  soup,  bacon,  apple  sauce,  bread. 

Bread,  butter,  oatmeal,  fried  bacon,  coffee,  tea. 
Soup,  beef,  bread. 


HOSPITAL  DIETARIES 


763 


Fbiday  : 

Breakfast : 
Diwner: 

Satubday : 

Breakfast : 
Dinner : 


Sunday : 

Breakfast: 

Dinner: 

Supper: 
Monday : 

Dinner: 
Ttjesday  : 

Supper: 

Dinner: 
Wednesday  : 

Dinner : 
Thursday  : 

Dinner : 
Fkiday  : 

Dinner: 
Saturday : 

Dinner : 


Bread,  butter,  salt  herring,  mush,  molasses,  cott'ee,  tea. 
Mutton  soup,  bread,  rice,  milk. 

Oatmeal,  Hamburg  steak,  bread,  butter,  coffee,  tea. 
Hash  soup,  bread,  apple  sauce. 

For  Farmers 

Every  day,  bread,  butter,  ham  or  other  meat,  coffee. 

Soup,  bacon,  bread. 

Bread,  coffee,  cold  beef,  stewed  prunes  or  apples. 

Soup,  beef,  bread. 

Every  day,  bread,  coffee,  cold  meat. 
Hash  soup,  bread. 

Hash  soup,  bread. 

Soup,  beef,  bread. 

Mutton  soup,  bread. 

Hash  soup,  bread. 

For  Insane  Department 

Bread,  coffee,  sausage   ( in  winter  months ) . 
Bacon,  soup,  bread. 
Bread,  coffee,  molasses. 

Bread,  coffee. 
Soup,  beef,  bread. 
Bread,  coffee. 

Bread,  coffee. 

Soup,  beef,  bread,  rice. 

Bread,  coffee,  stewed  fruit. 

Bread,  coffee. 

Soup,  hash,  bread. 

Bread,  coffee,  stewed  fruit. 

Bread,  coffee,  butter. 

Soup,  beef,  bread. 

Bread,  coffee,  cakes,  cheese,  and  crackers. 

Bread,  coffee,  mush  and  molasses. 
Soup,  mutton,  bread. 
Bread,  coffee,  stewed  fruit. 

Bread,  coffee. 

Soup,  hash,  bread. 

Bread,  coffee,  ginger-suaps,  cheese. 


Sunday  : 

Breakfast : 

Dinner: 

Supper : 
Monday : 

Breakfast : 

Dinner : 

Slipper : 
Tuesday : 

Breakfast : 

Dinner: 

Supper: 
Wednesday  : 

Breakfast : 

Dinner : 

Supper: 
Thursday: 

Breakfast : 

Dinner : 

Supper : 
Friday  : 

Breakfast : 

Dinner : 

Supper: 
Saturday : 

Breakfast : 

Dinyier: 

Supper: 

The  women  are  given  butter  on  Thursdays,  and  those  on  sick  diet 
receive  butter,  eggs,  and  oatmeal  daily. 

DIET  OF  THE  ROBERT   GARRETT  FREE  HOSPITAL  FOR   CHILDREN, 
BALTIMORE.  MD. 

Breakfast :     Rolled  oats,  well  cooked,  one  tablespoonful  with  milk;   bread,  plain 
or  toasted,  one  to  three  slices;    butter,  size  of  Malaga  grape; 


764  DIETARIES  IN  PUBLIC  INSTITUTIONS 

egg,  soft-boiled,  one-half  of  one  to  one;   milk,  slightly  warmed, 
8  to  12  ounces. 
Dinner:  Chicken,  beef,  or  mutton,   1  tablespoonful  when  cut  fine;    or  broth 

(meat  or  oyster),  4  to  6  ounces,  or  meat  stews  with  rice,  1  or  2 
tablespoonfuls ;  baked  potatoes  or  rice,  1  tablespoonful;  bread, 
1  or  2  slices;  milk,  8  ounces;  custard-pudding,  junket,  1  table- 
spoonful, or  oranges  or  baked  apples,  one-half  of  one;  stewed 
fruit;  prunes,  1  tablespoonful;  cake,  ginger-bread,  1  inch  to  IJ 
inches  square. 
Bread,  2  or  3  slices;  butter,  size  of  small  grape;  or  crackers,  4  or 
5;  milk,  8  to  16  ounces. 

The  foregoing  is  for  a  child  three  years  old.  For  a  boy  of  eight 
or  for  a  girl  of  from  ten  to  twelve  years,  twice  this  amount  is  al- 
lowed. A  boy  of  twelve  requires  as  much  as  an  adult.  Older  chil- 
dren prefer  cold  milk  or  cocoa  now  and  then.  One  quart  of  milk 
daily  is  allowed  for  each  child.  Variety  does  not  appeal  to  children 
as  to  older  persons. 

House  Diet 
Sunday : 

Breakfast:    Rolled  oats,  bread,  butter,  cocoa,  milk   (warm). 

Dinner:         Chicken,   baked  potatoes,   oranges   or   stewed   fruit,   bread   and 
milk. 

Supper:  Bread,  butter,  crackers,  and  milk. 

Monday  : 

Breakfast:     Rolled  oats,  eggs,  toasted  bread,  hot  milk. 

Dinner:  Chicken  soup,  rice,  custard,  bread  and  milk. 

Supper:  Bread  and  butter,  crackers,  and  milk. 

Tuesday : 

Breakfast :     Rolled  oats,  bread  and  butter,  cocoa,  milk. 

Dinner:  Stew  of  beef,  rice  cakes,  or  junket,  bread  and  milk. 

Supper:  Bread  and  butter,  crackers,  milk. 

Wednesday  : 

Breakfast:     Rolled  oats,  eggs,  toast,  butter,  hot  milk. 

Dinner:  Steak  or  roast-beef,  rice,  prunes,  bread  and  milk. 

Supper:  Bread  and  butter,  crackers,  milk. 

Thursday  : 

Breakfast :     Rolled  oats,  bread  and  butter,  cocoa,  milk. 

Dinner:  Soup  or  stew  of  mutton,  rice,  ginger-bread,  bread  and  milk. 

Supper:  Bread  and  butter,  crackers,  milk. 

Friday  : 

Breakfast :     Rolled  oats,  toast,  eggs,  butter,  hot  milk. 

Dinner:  Oyster  stew,  rice,  bread  pudding,  bread  and  milk. 

Slipper:  Bread  and  butter,  crackers,  milk. 

Saturday : 

Breakfast :     Rolled  oats,  bread  and  butter,  cocoa,  milk. 

Dinner:  Lamb  chops  or  roast-beef,  rice,  baked  apples,  bread  and  milk. 

Supper:  Bread,  butter,  crackers,  milk. 

Light  diet  is  house  diet  without  meats. 

Light  diet  allows  bread,  milk,  rolled  oats,  soup,  rice,  junket,  etc. 

Milk  diet  consists  of  from  four  to  six  ounces  of  milk  every  two   or  three 
hours,  according  to  the  age  and  condition  of  the  child. 

Under  one  year,  modified  milk  according  to  physician's  prescription. 

All  water  used  in  diluting  milk  is  boiled  first. 

All  drinking-water  is  filtered  in  the  city. 

Spring  water  is  used  in  the  country. 

DIET-LIST  OF  THE  CHILDKEN'S  HOSPITAL  OF  BOSTON 
House  Diet — Children 
Breakfast:        Milk,  cereals,  eggs,  bread  and  butter. 


HOSPITAL  DIETARIES 


765 


Dinner:  Beef,  mutton,  or  chicken,  the  last  on  holidays  and  sometimes 

on   ISundays;    mashed   potatoes,    boiled   rice,   gravy,   bread 

or  rice  pudding,  custard  or  corn-starch,  fruit,  bread  and 

butter,  milk. 

Supper:  Bread  and  butter,  milk,  sometimes  eggs,  milk  at  10  and  at  4 

o'clock,  and  when  awake  during  the  night,  as  required. 
Milk  diet:         Eight  ounces  of  milk  every  two  liours  during  day,  every  four 

hours  during  the  night. 
Liquid  diet:      Beef,  mutton,  or  chicken  broth,  milk,  beef-juice,  fruit-juice. 
Special  diet:     Each  item  to  be  ordered  by  House  Officer:     Chicken,  oysters, 
ice-cream,  gelatin,   soups,   fruit,   egg-nog,   beef-juice,  milk, 
custard,  milk  toast. 
All   patients  are  to  be  put  on  milk  diet  unless  otherwise  ordered  by  House 
Officer. 

Operative    patients    are    to    receive    regular    house    diet    until    night    before 
operation  unless  otherwise  ordered. 

"Ether  meal":     Bouillon,  seven  ounces,  four  hours  before  operation. 


Sunday : 

Breakfast : 
Dinner : 

Supper : 
Monday  : 

Breakfast . 
Lunch : 
Dinner : 

Tuesday : 

Breakfast : 
Lunch : 
Dinner : 

Wednesday  : 
Breakfast . 
Lunch : 

Dinner : 

Thubsday  : 

Breakfast : 
Lunch : 
Dinner: 

Friday  : 

Breakfast . 
Lunch: 

Dinner : 

Saturday : 

Breakfast : 
Lunch : 
Dinner: 


Sunday : 

Breakfast : 

Dinner : 

Supper : 


Diet  for  Nurses 

"Force,"  baked  beans,  brown  bread,  toast,  coffee. 

Roast   turkey,   cranberries,   potatoes,   bread   and   butter,   celery, 

wine  cream. 
Shrimp  salad,  Parker  House  rolls,  quince  jam,  cake,  tea. 

Cereal,  pressed  ham,  muffins,  toast,  coffee. 
Mock  bisque  soup,  potato  salad,  doughnuts,  coffee. 
Roast  lamb,  potatoes,  lima  beans,  Harvard  pudding,  bread  and 
butter. 

Cereal,  boiled  eggs,  corn-meal,  gems,  toast,  coffee. 
Irish  stew,  dumplings,  peanut  cookies,  tea. 
Roast-beef,  potatoes,  cream  carrots,  lemon  jelly,  cake. 

Cereal,  salt-fish  balls,  muffins,  toast,  coffee. 

Cold    roast-beef,    cheese    fondu,    bread    and    butter,    cup    cakes 

(chocolate  frosting),  tea. 
Roast  veal,  potatoes,  stewed  tomatoes,  bread  and  butter,  rhubarb 

pie. 

Cereal,  Hamburg  steak,  muffins,  toast,  coffee. 
Tomato  soup,  bread  and  butter,  oranges,  coffee. 
Beefsteak,    potatoes,    macaroni    and    cheese,    bread    and    butter, 
caramel  custard,  caramel  sauce. 

Cereal,  creamed  fish,  muffins,  toast,  coffee. 

Sardine,  stuffed  tomatoes,  bread  and  butter,  gingerbread  cheese, 

coffee. 
Baked  fish,  potatoes,  lettuce  and  radish  salad,  bread  and  butter, 

Washington  pie. 

Cereal,  cottage  pie,  muffins,  toast,  coffee. 

Potato  soup,  string-beans,  salad,  bread  and  butter,  oranges,  tea. 

Boiled  lamb,  caper  sauce,  potatoes,  canned  corn,  peach  meringue. 

Diet  for  Help 

Cereal,  baked  beans,   bread  and  butter,  coffee.      (Men  servants, 

hot  meat.) 
Roast  veal,    boiled   onions,   potatoes,   bread   and   butter,   lemon 

jelly,  tea. 
Cold  ham,  hot  biscuit,  prunes,  tea. 


766 


DIETARIES  IN  PUBLIC  INSTITUTIONS 


Monday  : 

Breakfast:  Cereal,  hash,  bread  and  butter,  coffee. 

Dinner:  Roast  lamb,  beets,  potatoes,  blanc-mauge,  tea,  bread  and  butter. 

Supper:  Cold  meat,  bread  and  butter,  canned  plums,  tea. 
Tuesday : 

Breakfast:  Cereal,  bacon,  bread  and  butter,  coffee. 

Dinner:  Roast-beef,  macaroni,  doughnuts,  coffee. 

Supper:  Cold  meat,  hot  rolls,  apples,  tea. 
Wednesday  : 

Breakfast:  Cereal,  boiled  eggs,  bread  and  butter,  coffee. 

Dinner:  Roast  pork,  peas,  potatoes,  bread  and  butter,  tapioca  pudding, 
tea. 

Supper:  Baked  beans,  cold  meat,  hot  rolls,  canned  peaches,  tea. 
Thursday  : 

Breakfast :  Cereal,  sausages,  bread  and  butter,  coffee. 

Dinner:  Fried  ham  and  eggs,  potatoes,,  bread  and  butter,  cottage  pud- 
ding. 

Supper:  Pickled  pigs'  feet,  bread  and  butter,  prunes,  tea. 
Friday  : 

Breakfast:  Cereal,  boiled  eggs,  bread  and  butter,  coffee. 

Dinner:  Baked  fish,  tomatoes,  potatoes,  bread  and  butter,  rice  pudding, 
tea. 

Supper:  Creamed  salt  fish,  hot  rolls,  apple  sauce,  tea. 
Saturday : 

Breakfast:  Cereal,  bacon,  bread  and  butter,  coffee. 

Dinner:  Irish  stew,  bread  and  butter,  bananas,  tea. 

Supper:  Cold  meat,  bread  and  butter,  jam,  tea. 

Out-Patient  Department 

Directions  for  Feeding  the  Baby 

"Have  a  milkman  leave  the  milk  daily;  do  not  get  it  at  a  store. 
"The  mixed  milk  of  a  number  of  cows  is  better  than  one  cow's  milk. 
"Let  the  milk  stand  five  hours  in  a  cool  place   (if  the  cream  has  already  risen, 
this  is  not  necessary),  and  pour  off  the  upper  quarter  from  the  can  or  bottle. 
"Mix  the  food  in  the  following  proportions: 

Top-milk     ounces. 

Water     •  ounces. 

Lime-water    ounces. 

Sugar-of-milk    tablespoonfuls. 

"Give        ounces  at  a  feeding  every         hours." 

(Quantities  to  be  indicated  by  the  physician.* 
Diet-List 
Milk.  Beef-juice. 

Bread.  Soft-boiled  egg. 

Cracker.  Boiled  rice. 

Oatmeal.  Macaroni. 

Oatmeal  jelly.  All  the  water  the  child  wants.     No  other 

Potato.  food. 


GREAT  ORMOND  STREET  HOSPITAL  FOR  SICK  CHILDREN,  LONDON 

Milk  Diet 

Breakfast,  8  o'clock:    Milk,  one  half  pint;  bread,  two  ounces  with  butter. 
Dinner,  12  o'clock:     Rice  or  other  milk  pudding;   milk,  one-third  pint,  or  beef- 
tea,  one-half  pint. 
Tea,  !i  o'clock:  Milk,  one-half  pint,  with  two  ounces  of  bread  and  butter. 

Supper,  6  o'clock,  or 

set   aside   for    the 

night     and     early 

morning:  Milk,  one-half  pint,  with  two  ounces  of  bread  and  butter. 


HOSPITAL  DIETARIES 


767 


Fish  Diet 

Breakfast,  8  o'clock:   Milk  or  cocoa,  with,  suj^ar,  oiic-lialf  pint;   bread,  two  and 

one-half  ounces  witli  butter. 
Dinner,  12   o'clock:     Fish,  one-half  ounce,  boiled;  bread,  one  ounce;  mashed  pota- 
toes, three  ounces;  rice  or  milk  pudding. 
Tea,   ff  o'clock:  Bread,   two   and   one-half   ounces   with   dripping,   butter   or 

treacle;  milk,  one-third  pint. 
Supper  6  o'clock,  or 
set   aside   for    the 
night     and     early 
morning:  Bread  with  butter  or  dripping;  milk,  one-third  pint. 

Meat  Diet 

Breakfast,  S  o'clock:   Milk   or  cocoa   witli   sugar,   one-half   pint;    bread,   two  and 

one-half  ounces,  with  butter. 
Dinner,  12   o'clock:     Roast   or    boiled    mutton    or    roast-beef,    two    and    one-half 
ounces;    mashed  potatoes,   four  ounces;    rice  and  milk 
pudding. 
Tea,  ^  o'clock:  Bread,  two  and   one-half  ounces  with  dripping,   butter,   or 

treacle;  milk,  one-third  pint. 
Supper,  6  o'clock,  or 
set    aside   for    the 

early     night     and  Bread,   two    ounces,    with    butter   or    dripping;    milk,    one- 
morning :  third  pint. 

Diet  Ingredients. — Water  or  barley-water  may  be  mixed  with  the  milk  when 
used  as  a  beverage,  so  long  as  the  regulation  quantity  of  milk  is  given  in  the 
twenty-four  hours. 

Greens,  carrots,  or  turnips,  etc.,  should  be  added  twice  a  week  to  all  fish  and 
meat  diets  that  include  potatoes. 

Tea,  sponge-cake,  fruit,  water-cress,  mutton  chops,  chicken,  eggs,  beef-essence, 
wine,  or  brandy  may  be  ordered  as  "extras"  by  the  medical  officers 

Fancy  Diet 

"Fancy  Diet"  may  be  ordered  in  exceptional  cases,  the  child  being  allowed  what- 
ever he  can  take — meat,  fish,  chicken,  sausage,  etc.,  with  frequent  variation. 

All  diets  are  adjusted  for  children  of  the  age  of  seven  years;  apportionment  is 
to  be  arranged  in  the  w^ards  according  to  the  age  and  needs  of  the  child. 


RECIPES 
BEVERAGES 

Lime  Water. — Into  an  earthen  jar  containing  hot  water  stir  a 
handful  of  fresh  unslaked  lime.  Pour  off  and  throw  away  the  water 
as  soon  as  it  has  settled.  This  first  water  contains  the  soluble  potash 
salts  which  may  be  present  in  the  lime.  Add  more  water,  allow  it  to 
settle ;  then  decant  the  clear  fluid  and  bottle  it.  Water  may  again  be 
added  to  the  lime,  and  the  mixture  covered  and  allowed  to  stand  to  be 
decanted  as  needed. 

Almond  Milk. — Blanch  one  pound  of  sweet  and  two  of  bitter 
almonds  that  have  been  soaked  in  cold  water  for  twenty-four  hours. 
This  is  done  by  pouring  boiling  water  over  the  almonds,  when,  after  a 
few  minutes,  they  can  easily  be  pressed  out  of  their  hulls.  Grind  the 
almonds  in  a  mill  or  pound  them  in  a  mortar;  mix  with  a  half -pint 
of  warm  milk  or  water,  and  allow  the  mixture  to  stand  two  hours, 
after  which  strain  through  a  cloth,  pressing  the  juice  out  well.  Thirty 
grams  of  almonds  yield  200  calories  of  heat;  250  grams  of  milk  yield 
1700  calories. —  (Wegele.) 

Brandy«and=egg  Mixture. — Rub  the  yolks  of  two  eggs  with  half 
an  ounce  of  white  sugar;  add  4  ounces  of  cinnamon  water  and  then 
4  ounces  of  brandy.  Dose :  One  or  two  teaspoonfuls  every  two 
hours,  according  to  age. —  {Stokes.) 

Brandy=and=egg  Mixture  for  Infants. — Beat  up  well  the  yolk  of 
a  raw  egg ;  ten  drops  of  brandy ;  one  teaspoonful  of  cinnamon  water ; 
one  coffeespoonful  of  white  sugar. —  (Louis  Starr.) 

Cold  Egg=nog. — Beat  up  an  egg;  add  to  it  two  teaspoonfuls  of 
sugar,  a  glassful  of  milk,  and  a  tablespoonful  of  brandy  or  good 
whisky ;  mix  thoroughly. 

Hot  Egg-nog. — Beat  up  the  yolk  of  one  egg ;  add  a  teaspoonful  or 
two  of  sugar,  and  a  glassful  of  hot  milk ;  strain,  and  add  a  tablespoon- 
ful of  brandy  or  old  whisky,  or  flavor  Avith  nutmeg  or  wine. 

Egg  Broth. — Beat  up  an  egg,  and  add  to  it  half  a  teaspoonful  of 
sugar  and  a  pinch  of  salt ;  over  this  pour  a  glass  of  hot  milk  and  serve 
immediately.  Hot  water,  broth,  soup,  or  tea  may  be  used  in  place  of 
milk. — Drexel  Institute. 

Egg  Cordial. — Beat  up  the  white  of  an  egg  until  light ;  add  a  table- 
spoonful  of  cream  and  beat  up  together,  then  add  two  teaspoonfuls  of 
sugar  and  a  tablespoonful  of  brandy. 

Caudle. — Beat  up  an  egg  to  a  froth;  add  a  wineglassful  of  sherry- 
wine,  and  sweeten  with  a  teaspoonful  of  sugar ;  if  desired,  flavor  with 

768 


BEVERAOES  769 

lemon  peel.  Stir  this  mixture  into  a  half -pint  of  gruel;  over  this 
grate  a  little  nutmeg  and  serve  with  hot  toast. 

Albumin  Water. — Beat  the  white  of  an  egg  until  very  light  and 
strain  through  a  clean  napkin.  Add  six  ounces  of  water.  If  intended 
for  an  infant  a  pinch  of  salt  may  be  added.  A  teaspoonful  or  more 
of  sugar  and  a  teaspoonful  or  more  of  lemon  juice,  orange  juice,  or 
sherry  wine  may  be  added  to  enhance  its  palatableness.  This  drink 
may  also  conveniently  be  made  by  placing  all  the  ingredients  in  a 
lemonade-shaker,  shaking  until  thoroughly  mixed,  and  then  straining. 
Serve  cold. 

Apple  Water. — Pour  a  cupful  of  boiling  water  over  two  mashed 
baked  apples ;  cool,  strain,  and  sweeten.  Serve  with  shaved  ice  if 
desired. 

Tamarind  Water. — Pour  a  cupful  of  boiling  water  over  a  table- 
spoonful  of  preserved  tamarinds;  allow  this  to  stand  until  cool,  then 
strain,  and  serve  with  shaved  ice. 

Currant  Juice. — Take  an  ounce  of  currant  juice  or  a  tablespoonful 
of  currant  jelly.  Over  this  pour  a  cupful  of  boiling  water — use  cold 
water  with  the  juice — and  sweeten  to  taste. 

Lemonade  No.  i. — Take  the  juice  of  one  lemon  or  three  tablespoon- 
fuls  of  lemon  juice ;  add  from  one  to  three  tablespoonfuls  of  sugar  and 
a  cupful  (6  ounces)  of  cold  water.  Serve  with  cracked  or- shaved  ice 
if  desired. 

Lemonade  No.  2. — Pare  the  rind  from  one  lemon,  cut  the  lemon 
into  slices,  and  place  both  in  a  pitcher  with  an  ounce  of  sugar.  Over 
this  pour  a  pint  of  boiling  water  and  let  it  stand  until  cool.  Strain 
and  serve  vrith  cracked  ice. —  {Pavy.) 

Effervescing  Lemonade. — This  may  be  made  b}'  using  a  carbonated 
water  or  by  adding  half  a  teaspoonful  of  bicarbonate  of  soda  or  potash 
to  a  glassful  of  either  of  the  foregoing  lemonades.    ' 

Albuminized  Lemonade. — Shake  together  a  cupful  of  water,  two 
teaspoonfuls  of  lemon  juice,  two  teaspoonfuls  of  sugar,  and  the  white 
of  one  egg.     Serve  at  once. 

Orangeade. — Cut  the  rind  from  one  orange ;  over  the  rind  pour  a 
cupful  of  boiling  water;  then  add  the  juice  of  the  orange  and  a 
tablespoonful  of  sugar;  cool,  strain,  and  serve  with  shaved  ice  if 
desired.  If  this  is  too  sweet,  a,  teaspoonful  of  lemon  juice  may  be 
added. 

Imperial  Drink. — Add  a  teaspoonful  of  cream  of  tartar  to  a  pint 
of  boiling  water;  into  this  squeeze  the  juice  of  half  a  lemon,  or  more 
if  desired ;  sweeten  to  taste  and  serve  cold.  This  drink  is  most  useful 
in  fevers  and  in  nephritis. 

Flaxseed  Tea. — Add  six  tablespoonfuls  of  flaxseed  to  a  quart  of 
water;  boil  for  half  an  hour;  cool,  strain,  sweeten,  and  if  desired 
flavor  with  a  little  lemon  juice. 

Linseed  Tea. — To  a  pint  of  water  add  two  tablespoonfuls  of  lin- 
49 


770  RECIPElS 

seed,  the  juice  of  half  a  lemon;  V^  ounce  of  bruised  licorice  root  (or  a 
piece  of  licorice  the  size  of  a  lilbert),  and  rock-candy  to  taste.  Boil 
for  one  and  one-half  hours  and  strain. —  {Yeo.) 

Orgeat. — Blanch  two  ounces  of  sweet  almonds  and  four  bitter  al- 
mond seeds.  Add  a  little  orange-flower  water  and  pound  into  a  paste ; 
rub  this  with  a  pint  of  milk  diluted  with  a  pint  of  water  until  it 
forms  an  emulsion.  Strain  and  sweeten  with  sugar.  (A  demulcent 
and  nutritive  drink.)  — (Pa ry.) 

Mulled  Wine. — One-fourth  of  a  cupful  of  hot  water,  one-half  inch 
of  stick  cinnamon,  two  cloves,  a  tiny  bit  of  nutmeg,  one-half  cupful 
of  port  (heated),  two  tablespoonfuls  of  sugar.  Boil  all  the  ingre- 
dients except  the  wine  and  sugar  for  ten  minutes ;  then  add  the  wine 
and  sugar,  strain,  and  serve  very  hot. —  {Drexel  Institute.) 

Grape  Juice. — Pluck  Concord  grapes  from  the  stem.  Wash  and 
heat  them,  stirring  constantly'.  When  the  skins  have  been  broken, 
pour  the  fruit  into  a  jelly  bag  and  press  slightly.  Measure  the  juice 
and  add  one-quarter  the  quantity  of  sugar.  Boil  the  juice  and  sugar 
together  and  then  pour  into  hot  bottles;  cork  and  seal  with  paraffin 
or  equal  parts  of  shoemaker's  wax  and  resin  melted  together.  Less 
sugar  may  be  used. —  {Drexel  Institute.) 

Grape  Juice  and  Egg. — Beat  the  white  of  an  egg  lightly,  strain 
through  a  napkin,  and  add  to  it  two  tablespoonfuls  of  grape  juice. 
Fill  a  large  wineglass  half  full  of  cracked  ice.  Pour  the  egg  and 
grape  juice  over  this,  sprinkle  sugar  over  it,  and  serve. 

Oatmeal,  Barley,  or  Rice  Water. — From  the  grain:  Use  two 
tablespoonfuls  of  grain  to  a  quart  of  w^ater.  The  grain  should  have 
been  previously  soaked  overnight  or  at  least  for  a  few  hours.  When 
required  for  an  emergency,  the  soaking  may  be  dispensed  with  and  the 
grain  boiled  for  five  minutes  instead.  The  water  in  which  the  grain 
was  soaked  should  be  poured  off  and  fresh  water  added  before  cook- 
ing. The  grain  should  be  boiled  for  several  hours,  water  being  added 
from  time  to  time  to  keep  the  quantity  up  to  a  quart.  Strain.  This 
makes  a  somewhat  thin,  watery  gruel. 

From  prepared  fours:  Various  brands  of  prepared  grain  flours 
are  on  the  market,  such,  for  example,  as  Kobinson's  Barley  Flour. 
These  are  all  somewhat  similar  in  preparation.  From  two  rounded 
teaspoonfuls  to  a  tablespoonful  of  the  prepared  flour  is  added  to  a 
pint  of  boiling  water,  and  this  is  boiled  for  from  fifteen  to  thirty 
minutes  and  then  strained.     No  previous  soaking  is  required. 

CEREAL  AND  CEREAL  GRUELS 

Either  the  grain  itself  or  the  specially  prepared  flour  may  be  used. 
When  the  grains  are  used  they  should  be  spread  on  a  clean  table  and 
all  foreign  substances  removed.  If  the  whole  grains  be  used,  it  is  well 
to  wash  them,  after  picking  them  over,  with  two  or  three  changes  of 
cold  water. 


CEREAL  AyD  CEREAL  GRUELS  '771 

Cereals  are  best  cooked  in  a  double  boiler.  The  lower  part  should 
be  tilled  about  oiie-third  full  of  water,  and,  if  more  is  added  during 
the  cooking,  it  should  always  be  boiling  hot.  The  cereal  should  be 
cooked  over  the  tire  for  ten  or  fifteen  minutes.  The  water  should  be 
boiled  tirst  and  then  salted.  The  cereal  is  added  gradually  and  the 
whole  stirred  to  prevent  it  from  burning.  It  should  then  be  placed 
in  a  double  boiler  and  steamed  until  thoroughly  cooked.  Cereals, 
like  other  starchy  foods,  require  thorough  cooking.  ^lost  recipes 
allow  too  short  a  time.  Oatmeal  especially  should  be  mentioned.  It 
develops  a  better  flavor  if  cooked  for  three  hours  or  more,  and  it  is 
better  when  it  is  prepared  the  day  before  and  reheated  when  used. 
It  should  be  just  thin  enough  to  pour  when  taken  out  of  the  boiler, 
and  when  cooled  should  form  a  thin  jell.y. 

Any  cereal  mush  maj'  be  thinned  w4th  water,  milk  or  cream  and 
made  into  a  gruel,  or  the  gruel  may  be  made  directly  from  the  grain 
or  flour.  Gruels  should  be  thin,  not  too  sweet  nor  too  highly  flavored, 
and  served  very  hot.  ]\Iilk  gruels  should  be  made  in  a  double  boiler. 
Gruels  may  be  made  more  initritious  by  the  addition  of  whipped  egg, 
either  the  white  or  yolk  or  both,  and  the  various  concentrated  food 
products. 

When  cereal  flours  are  used,  the  flour  should  be  rubbed  to  a  smooth 
paste  with  a  little  cold  water  and  added  slowly  to  boiling  water, 
stirring  constantly  until  it  is  thoroughly  mixed. 

LENGTH  OF  TIME  TO  COOK  CEREALS 

Cornmeal  mush:  Boil  10  minutes,  then  steam  for  3  hours  or  more. 

Oatmeal:  "'     "  "  "  ''         "    IJ     "  " 

Irish  Oatmeal:  "     "  *'  *'  "         "    8       "  " 

Wheatena:  "     "  "  "  "         "'    M     "  '' 

Gluten  7nusli :  "     30         " 

Steamed   Rice:  Boil  for  one  hour. 

Boiled  Rice:  Boil  for  twenty  minutes  or  until  soft. 

Arrowroot  Gruel. — Dissolve  half  a  teaspoonful  of  sugar  and  a 
quarter  of  a  teaspoonful  of  salt  in  a  cupful  of  water,  and  heat. 
Mix  half  a  tablespoonful  of  arrowroot  flour  with  a  little  w^ater  and 
add  to  the  heated  Avater.  Boil  for  twenty  minutes,  stirring  con- 
stantly; then  add  a  cupful  of  milk,  bring  to  a  boil,  strain,  and  serve 
hot. 

Barley  Gruel. — Proceed  as  above,  using  a  tablespoonful  of  Robin- 
son's Barley  Flour  instead  of  arrowroot. 

Oatmeal  Gruel. — As  above,  but  use  oatmeal,  and  boil  for  half  an 
hour  or  longer,  before  adding  the  milk. 

Flour  Gruel. — Proceed  as  in  making  arrowroot  gruel,  using  instead 
a  tablespoonful  of  wheat  flour.  Flavor  with  lemon  juice,  cinnamon, 
nutmeg  or  vanilla. 

Farina  Gruel. — Proceed  as  in  making  arrowroot  gruel,  using  in- 
stead a  tablespoonful  of  farina,  and  boil  but  ten  minutes  before  add- 
ing the  milk. 


772  RECIPES 

Imperial  Granum  Gruel. — As  iu  the  preceding,  but  use  imperial 

grauum  instead  of  farina. 

Cracker  Gruel  No.  i. — Use  two  tablespoonfuls  of  cracker  crumbs 
and  proceed  as  above.  Cook  only  two  or  three  minutes  and  do  not 
strain. 

Cracker  Qruel  No.  2. — Brown  the  crackers,  and  reduce  to  a  pow- 
der by  means  of  a  rolling-pin.  Add  three  tablespoonfuls  of  the  pow- 
dered crackers  to  half  a  cupful  of  milk  and  half  a  cupful  of  boiling 
water ;  cook  for  ten  minutes ;  then  add  one-fourth  of  a  teaspoonf ul  of 
salt  and  serve. —  {Drexel  Institute.) 

Racahout  des  Arabes. — This  is  a  French  preparation  with  a 
chocolate  flavor  which  makes  a  most  delicious  gruel.  Follow  the 
directions  given  for  farina  gruel.  A  homemade  racahout  may  be 
made  as  follows:  Take  one  pound  of  cocoa,  one  pound  of  confec- 
tioner's powdered  sugar,  one  pound  of  rice  flour,  two  ounces  of  ar- 
rowroot flour,  and  two  ounces  of  sugar  of  milk.     Mix  thoroughly. 

Flour  Ball. — Tie  half  a  pint  of  flour  in  a  square  of  flne  cheese  cloth, 
making  a  very  tight  ball.  Place  this  in  a  pot  of  boiling  water  and 
cook  for  four  or  five  hours.  After  taking  out  of  the  cloth,  peel  off 
the  outside  and  grate  the  hard  ball.  Dry  in  the  oven  and  keep  in  a 
covered  jar.  This  is  useful  for  making  gruels  for  diluting  milk  for 
infants. 

Flour=ball  Qruel. — Proceed  as  for  arrowroot  gruel,  using  two  tea- 
spoonfuls  of  the  above  grated  flour  rubbed  up  in  cold  water,  and  stir 
into  a  point  of  boiling  water.     Cook  this  for  ten  minutes. 

Meal  Soup. — This  is  prepared  by  browning  two  tablespoonfuls  of 
wheat  flour  in  a  clean  frying  pan,  stirring  continuously.  One-half 
pint  of  water  and  one-half  pint  of  milk  are  brought  to  a  boil,  and  a 
heaping  tablespoonful  of  the  browned  flour  is  blended  with  water 
and  then  stirred  into  the  mixture. 

Cornmeal  Gruel  No.  i. — Use  two  tablespoonfuls  of  cornmeal  and 
one  of  flour,  a  teaspoonful  each  of  sugar  and  salt,  one  quart  of  hot 
water  and  a  cupful  of  milk.  Proceed  as  in  making  arrowroot  gruel, 
boiling  in  a  double  boiler  for  three  hours. 

Cornmeal  Gruel  No.  2. — Take  a  tablespoonful  of  cornmeal  and 
moisten  with  a  little  cold  water.  Stir  this  into  a  pint  of  boiling  water 
to  which  a  pinch  of  salt  has  been  added.  Cook  for  three  hours  in  a 
double  boiler,  or  for  thirty  minutes  directly  over  the  fire.  In  the 
latter  case  it  must  be  stirred  constantly. 

Gluten  Gruel. — Mix  a  tablespoonful  of  gluten  flour  with  one-fourth 
of  a  cupful  of  cold  water  and  stir  this  into  one  cupful  of  boiling 
salted  water.  Cook  directly  over  the  fire  for  fifteen  minutes;  then 
add  one  clove  and  cook  over  boiling  water  for  a  half -hour. —  {Drexel 
Institute.) 

Barley  and  Oatmeal  Jelly. — From  the  grain:  Prepare  the  grain 
as  directed  for  barley  water.     Use  from  four  to  six  tablespoonfuls  of 


CEREAL  AXD  CEREAL  GRUELS  773 

grain  to  the  quart  of  water.  Boil  thoroug'hly  for  several  hours 
until  the  grain  is  thoroughly  cooked.  Strain  and  cool.  The  jelly 
when  hot  should  be  just  thick  enough  to  pour. 

From  the  prepared  flours:  Use  two  tablespoonfuls  of  the  flour  to  a 
pint  of  water.     Boil  from  fifteen  to  thirty  minutes  and  strain. 

Partially  Digested  Cereals  Prepared  at  the  Table. — To  a  sauce 
of  well-cooked  oatmeal,  wheaten  grits,  or  rice,  at  the  customary  tem- 
perature, add  one  or  two  teaspoonfuls  of  Fairchild's  Diastasic  Es- 
sence of  Pancreas,  or  fifteen  grains  of  Fairchild's  Dry  Extract  of 
Pancreas.  Stir  for  a  few  minutes  before  eating.  When  the  ferments 
are  added  to  the  very  hot  foods  their  power  becomes  impaired. 

Tapioca  Jelly. — Soak  a  cupful  of  tapioca  of  the  best  quality  in  a 
pint  of  cold  water  for  two  hours;  when  soft,  place  in  a  saucepan 
with  sugar,  the  rind  and  juice  of  one  lemon,  a  pinch  of  salt,  and 
another  pint  of  water;  stir  the  mixture  until  it  boils;  turn  into  a 
mold  and  set  away  to  cool;  if  desired,  a  glassful  of  wine  may  be 
added. —  {Barfh  olow.) 

Tapioca  Soup.^ — Boil  a  pint  of  meat  broth  or  stock,  and,  while  stir- 
ring constanth',  sprinkle  in  •%  ounce  of  previously  washed  tapioca. 
Cover  the  saucepan,  and  let  it  stand  until  the  tapioca  is  quite  soft. 
Skim  and  serve. —  {Yea.) 

Chestnut  Puree. — One  pound  of  chestnuts  are  peeled,  and  boiled 
in  water  until  the  second  (inside)  skin  comes  off  easily.  The  chest- 
nuts are  placed  in  a  sieve  until  all  the  water  drains  off.  They  are 
then  washed  in  a  dish  and  afterward  pressed  through  a  sieve.  ]Melt 
three  ounces  of  butter  in  a  stewpan  on  the  fire,  add  a  little  salt  and 
sugar — enough  to  cover  the  point  of  a  knife — and  then  the  chestnuts. 
Stew  them  for  half  an  hour,  stirring  frequently;  pour  in  enough 
bouillon  so  that  the  mush  does  not  get  too  thick. —  (Wegele.) 

BREAD 

Drexel  Institute  Bread  Recipe. — For  two  loaves  take  two  cupfuls 
of  warm  milk  or  water,  two  teaspoonfuls  of  salt  and  two  of  sugar, 
a  tablespoonful  of  lard  or  butter,  one-half  cake  of  compressed  yeast, 
and  about  four  pounds  of  fiour.  Put  the  water  or  milk,  salt,  sugar, 
and  fat  into  a  bowl.  Dissolve  the  yeast  in  warm  water;  add  it  and 
the  flour  gradually ;  when  stiff  enough  to  handle,  turn  the  dough  on  a 
floured  board  and  knead  until  soft  and  elastic.  Put  it  back  into  the 
bowl,  and  let  it  rise  in  a  warm  place  until  it  is  double  its  bulk. 
Then  divide  it  into  loaves  or  shape  into  biscuits.  Allow  these  to  rise 
in  the  pan  in  which  they  are  baked.  Cover  the  bread  and  again 
allow  it  to  double. its  bulk.  Bake  loaves  one  hour  in  a  hot  oven.  The 
large  amount  of  yeast  allows  the  bread  to  be  made  and  baked  in  three 
hours. 

Brown  Bread. — Take  one-half  cupful  scalded  milk,  one-half  cupful 
water,  one  teaspoonful  salt,  one-half  tablespoonful   butter,  one-half 


774  RECIPES 

tablespoonful  lard,  two  tablespoonfuls  of  molasses,  one-half  cupful 
white  flour,  sufficient  Graham  flour  to  knead,  and  three-quarters  of  a 
yeast  cake  dissolved  in  one-quarter  of  a  cupful  of  luke-warm  water. 
Prepare  the  same  as  white  bread.  Instead  of  Graham  flour,  equal 
parts  of  Graham  flour  and  white  flour  may  be  used  in  kneading. 

Nut=brown  Bread. — The  same  as  preceding,  with  one  cupful  of  nuts 
chopped  and  added. 

Whole-wheat  Bread. — Dissolve  a  quarter  of  a  yeast  cake  in  a 
tablespoonful  of  lukewarm  water.  Pour  half  a  cupful  of  hot  water 
over  half  a  cupful  of  milk,  and  when  lukewarm  add  tlie  yeast  and 
half  a  teaspoonful  of  salt.  To  this  add  a  cupful  whole-wheat  flour 
and  beat  for  five  minutes.  Cover  and  allow  this  to  stand  in  a  warm 
place  for  two  hours  and  a  half.  Then  add  whole-wheat  flour  grad- 
ually, mixing  the  mass  until  it  can  be  kneaded.  Knead  until  elastic ; 
shape  and  place  into  baking-pans.  Cover  and  allow  to  stand  in  a 
warm  place  until  it  doubles  its  bulk.  Prick  the  top  with  a  fork  and 
bake  for  one  hour.     The  oven  should  not  be  hot  as  for  white  bread. 

Pulled  Bread. — Use  bread  made  with  water.  Make  into  long 
loaves,  and  as  soon  as  baked  take  off  the  crust.  Pull  into  stick-shaped 
pieces  and  brown  slightly  in  a  slow  oven. 

Zwieback. — Cut  stale  bread  in  slices  and  place  in  the  oven  and 
allow  to  remain  until  the  slice  is  colored  golden  brown.  Zwieback  is 
a  particularly  desirable  food  for  infants  and  invalids. 

Bran  Muffins  for  Constipation  [Musser  and  Piersol). — Bran  flour 
two  cups,  wheat  flour  two  cups,  sour  milk  one  cuj),  molasses  four 
tablespoonfuls,  a  little  salt.  Bake  in  muffin  pans  (one  to  be  taken  at 
each  meal). 

Agar=agar  Crackers. — These  may  be  made  by  adding  fine  agar 
flour  to  the  flour  from  which  the  biscuit  or  crackers  is  to  be  made. 
About  five  grams  of  agar  flour  should  be  added  for  each  biscuit. 

Bran  Biscuits 

Bran (50  gms.      (  Horse  bran) 

Salt    i  teaspoontui 

Agar-agar,  powdered 6  gms. 

Cold  water   100  c.cm.   ( -\  glass) 

Tie  bran  in  cheese  cloth  and  wash  under  cold  water  tap  until  water  is  clear. 
Heat  agar-agar  in  the  water  (100  c.cm.)  to  the  point  of  boiling.  Add  to  washed 
bran  the  salt  and  agar-agar  solution  ( hot ) .  Mold  into  two  cakes.  Place  in  pan 
on  oiled  paper;  then,  when  firm  and  cool,  bake  in  moderate  oven  30  to  40 
minutes. 

Laxative  Bread 

1  egg  2  cup  of  sugar 

i  cup  of  molasses  1  cup  of  sour  milk 

i  cup  of  dry  rolled  oats  3  cups  of  Graliam  flour 

1  teaspoonful  soda  1   tablespoonful   of  warm  water 

Whip  the  egg  and  sugar  together  and  add  the  molasses  last. 

Bake  in  slow  oven  for  one  hour. 

Use  pulverized  bran  if  Graham  flour  is  not  to  be  had. 

This  quantity  makes  one  loaf. 


SOUPS  MUTHOUT  MEAT 


775 


VEGETABLES 
TIME  TABLE  FOR  COOKING  VEGETABLES  IN  WATER 


(  Dkkxkl  1 

Potatoes   2r)-;50  miii. 

Carrots     '55-4.5 

Turnips     45      " 

Beets    (young)    45      " 

Beets   (old)    3-4     hrs. 

Tomatoes    1-3 

Onions    45-60  min. 

Cabbage    45-60      '• 

Cauliflower    20-30      " 

Asparagus    20-30      " 


NSTITUTE) 

Spinach     30-45  min. 

Celery 20-30      " 

Parsnips     30-45      " 

Green   peas    30-40 

String-beans     1-3     hrs. 

Lima  Beans 1  hr.  or  more. 

Greeu  corn 12-20  min. 

Rice     20-45      '• 

Macaroni    45-60 


GENERAL  RULES  FOR  COOKING  VEGETABLES 

Wash  thoroiig'hly ;  pare  or  scrape  if  skins  must  be  removed.  Stand 
in  cold  water  until  cooked,  to  keep  them  crisp  and  prevent  their  being 
discolored.  Cook  in  boiling  water;  the  water  must  be  kept  at  the 
boiling-point.  Use  two  teaspoonfuls  of  salt  with  two  quarts  of  water; 
put  the  salt  into  the  water  when  the  vegetables  are  partially  cooked. 
The  water  in  which  vegetables  are  cooked  is  called  vegetable  stock. 

Fresh  green  vegetables  require  less  water  than  others. 

Cabbage,  cauliflower,  onions,  and  turnips  should  be  cooked  uncov- 
ered in  a  large  amount  of  water. 

All  vegetables  must  be  drained  as  soon  as  tender.  Season  with 
salt  and  pepper  and  serve  hot  with  butter  or  sauce. 

The  color  may  be  kept  in  green  vegetables,  such  as  spinach,  by  pour- 
ing cold  water  through  them  after  draining. 

Cold  vegetables  may  be  used  for  salads  or  may  be  placed  in  a  baking- 
dish  with  one-half  the  quantity  of  sauce  (2  cupfuls  vegetables  and  1 
cupful  sauce),  covered  with  buttered  crumbs,  and  browned  in  a  hot 
oven. 


Sauce  for  Vegetables: 

3  tablespoonfuls  of  butter 
3  tablespoonfuls  of  flour 
1  teaspoonful  of  salt 


White  pepper 
1   cupful  of  milk 
1  cupful  of  stock 


Salad  Dressing  for  the  Obese. — Two  tablespoonfuls  vinegar,  a 
pinch  of  salt  and  paprika,  one-quarter  tea.spoooful  mustard  (dry),  one 
teaspoon  chives  chopped  fine  or  parsley,  one  teaspoonful  tomato  cat- 
sup or,  if  preferred.  Walnut  or  Worcestershire  sauce.  Rub  the  salad 
bowl  with  an  onion  or  garlic,  mix  the  salt,  mustard,  and  paprika 
together.  Add  the  vinegar,  catsup  and  chives  and  pour  over  the 
salad.    A  finely  chopped  hardboiled  egg  may  be  used  from  time  to  time. 


776  RECIPES 

SOUPS  WITHOUT  MEAT 
(Deexel  Institute) 

These  soups  are  thickened  by  using  butter  and  flour ;  this  prevents 
a  separation  of  the  thicker  and  thinner  parts  of  the  soup.  The  but- 
ter should  be  heated  until  it  bubbles,  the  flour  and  seasoning  added, 
and  enough  of  the  hot  liquid  to  make  a  smooth  sauce  thin  enough  to 
pour  easily ;  this  should  be  poured  into  the  rest  of  the  hot  liquid  and 
cooked  in  a  double  boiler  until  the  soup  is  of  the  proper  consistency. 

In  soups  made  of  dried  peas  and  beans,  soda  is  used  to  soften  the 
casein ;  it  is  also  used  in  tomatoes  to  neutralize  the  acid.  These 
soups  must  be  served  in  hot  dishes  as  soon  as  ready.  Crisp  crackers, 
croutons,  or  soup  sticks  may  be  served  with  them. 

Crisp  Crackers: 

Split  and  butter  thick  crackers  and  brown  in  a  hot  oven. 

Cream=of=Tomato  Soup: 

1  can  tomatoes  i  cupful  of  flour 

^  teaspoonful  soda  3:^  teaspoonfuls  of  salt 

J  cupful  of  butter  j  teaspoonful  of  white  pepper 

1  quart  of  milk. 

Stew  the  tomatoes  slowly  one-half  to  one  hour,  strain,  and  add  soda  while  hot; 
make  a  white  sauce  and  add  the  tomato  juice.     Serve  immediately. 

Cream=of=Celery  Soup: 

IJ  cupfuls  of  celery  2  tablespoonfuls  of  butter 

1     pint  of  water  I  cupful  of  flour 

1     cupful  of  milk  }  teaspoonful  of  salt 

1  cupful  of  cream  J  teaspoonful  of  white  pepper 

Cook  the  celery  in  the  boiling  water  until  very  soft;  strain  and  add  the  hot 
liquid;  make  a  white  sauce  and  cook  until  it  is  thick  cream. 

Cream=of= Potato  Soup: 

3  potatoes  Yolks  of  2  eggs 

2  cupfuls  of  milk  1  teaspoonful  of  salt 
^  cupful  of  cream                              Pepper 

i  teaspoonful  of  onion  juice. 
Cook  the  potatoes  until  soft,  drain,  mash,  add  the  hot  liquid,  and  strain;  add 
the  beaten  yolks  and  seasoning.     Cook  in  a  double  boiler  until  the  egg  thickens, 
stirring  constantly.     Serve  immediately. 

Oyster  Stew: 

1     cupful  of  milk  ^  teaspoonful  of  salt 

1  pint  of  oysters  1  tablespoonful  of  butter 

Pepper. 
Heat  the  milk.     Cook   and   strain   the   oyster   juice.     Add   the   oysters,   which 
have  been  rinsed,  and  cook  until  the  edges  curl.     Add  seasoning,  butter,  and  hot 
milk.     Serve  at  once.     This  soup  may  be  thickened  with  a  tablespoonful  of  flour 
cooked  in  the  butter  as  for  white  sauce. 

Vegetable  Soup: 

1  handful  of  spinach. 

1  large  beet. 

2  carrots. 

Chop  fine  and  add  to  one  quart  of  water.  Boil  two  hours,  add  water  to  make 
quantity  up  to  one  quart,  and  strain.  Add  salt  if  desired.  This  contains  a 
large  amount  of  inorganic  salts. 


MILK  PREPARATIONS  ■  777 

MILK  PREPARATIONS 

Partially  Peptonized  Milk. — Into  a  clean  graniteware  or  porce- 
lain-lined saucepan  place  one  pint  of  milk,  four  ounces  of  water,  and 
the  contents  of  one  of  Fairchild's  peptonizing  tubes,  or  five  grains  of 
pancreas  extract  and  fifteen  grains  of  bicarbonate  of  soda.  Heat 
gradually  until  it  boils,  stirring  constantly.  Boil  gently  for  ten 
minutes,  strain  into  a  clean  bottle,  cork,  and  keep  in  a  cool  place. 
Before  using  shake  the  bottle  well ;  serve  hot  or  cold.  Prepared  in 
this  way  it  will  not  become  bitter. 

Peptonized  Milk  (Cold  Process.) — Mix  milk,  water  and  peptoniz- 
ing agents  as  directed  in  the  preceding  recipe,  and  immediately  place 
the  bottle  on  ice.  Use  when  ordinary  milk  is  required.  This  is  par- 
ticularly suited  for  dyspeptics  and  individuals  with  whom  milk  does 
not,  as  a  rule,  agree.     The  flavor  of  the  milk  remains  unchanged. 

Peptonized  Milk  (Warm  Process.) — Put  in  a  glass  jar  one  pint 
of  milk  and  four  ounces  of  cold  water ;  add  five  grains  of  extract  of 
pancreas  and  fifteen  grains  of  bicarbonate  of  soda.  After  mixing 
thoroughly,  place  the  jar  in  water  as  hot  as  can  be  borne  by  the  hand 
(about  115°  F.).  This  should  be  heated  for  from  six  to  twenty 
minutes.  At  the  end  of  this  time  it  may  be  placed  upon  ice  until 
required.  The  contents  of  one  of  Fairchild's  peptonizing  tubes  may 
be  used  in  place  of  the  pancreas  extract.  If  the  milk  is  to  be  kept  for 
any  length  of  time,  it  should  be  brought  to  a  boil,  to  prevent  the  for- 
mation of  too  much  peptone,  which  renders  the  milk  bitter. 

Hot  Peptonized  Milk. — Mix  together  the  usual  peptonizing  ingre- 
dients and  add  a  pint  of  fresh  cold  milk ;  after  thoroughly  shaking  the 
bottle,  place  it  on  ice.  When  needed  pour  out  the  required  amount, 
heat  it,  and  drink  it  as  hot  as  it  can  agreeably  be  taken.  If  required 
for  immediate  use,  the  ingredients  may  be  mixed  together  in  a  sauce- 
pan and  slowly  heated  to  the  proper  temperature. 

Effervescent  Peptonized  Milk. — Put  some  finely  cracked  ice  in  a 
glass ;  fill  it  half-full  of  Apollinaris,  Vichy,  or  siphon  water,  and  im- 
mediately add  the  peptonized  milk.  Drink  while  elfervescing. 
Brandy  may  be  added  if  desired. 

Specially  Peptonized  Milk. — This  is  to  be  used  in  the  preparation 
of  jellies,  punches,  and  all  recipes  where  the  milk  is  to  be  mixed  with 
fruit  juices  or  acids.  Prepare  according  to  the  hot  process ;  keep  the 
milk  at  a  temperature  of  115°  F.  for  one  hour;  pour  into  a  saucepan 
and  bring  to  a  boil.  If  required  hot,  this  may  be  used  immediately, 
or  it  may  be  set  aside  on  ice,  to  be  used  later.  If  not  heated  for  an 
hour,  the  milk  will  curdle  on  being  mixed  with  an  acid.  If  not  boiled, 
the  peptonizing  ferment  will  digest  gelatin  and  prevent  the  formation 
of  jelly. 

Peptonized  Milk  Jelly. — Soak  well  half  a  box  of  Cox's  gelatin  in 
four  ounces  of  water.     Take  one  pint  of  hot  specially  peptonized  milk 


778  RECIPES 

and  add  four  ounces  of  sugar.  Put  in  the  gelatin  and  stir  until  it  is 
dissolved.  Pare  one  fresh  lemon  and  one  orange,  and  add  the  rinds 
to  the  mixture.  Squeeze  the  lemon  and  the  orange  juice  into  a  glass, 
strain,  and  mix  with  two  or  three  tablespoonfuls  of  St.  Croix  rum,  or 
brandy,  if  preferred.  Add  the  juices  to  the  milk,  stirring  constantly. 
Strain,  and  allow  it  to  cool  to  the  consistence  of  syrup ;  when  almost 
ready  to  set,  pour  into  cups  and  set  in  a  cold  place.  Do  not  pour  the 
milk  into  moulds  until  the  mixture  is  nearly  ready  to  set,  otherwise 
it  will  separate  in  setting. 

Peptonized  Milk  Punch. — In  the  usual  milk  punch  recipes  the 
specially  peptonized  milk  may  be  used  in  place  of  ordinary  milk. 
Take  a  goblet  one-third  full  of  finely  crushed  ice ;  pour  on  it  a  table- 
spoonful  of  rum  and  a  dash  of  Curacao,  or  any  other  liquor  agreeable 
to  the  taste.  Fill  the  glass  with  peptonized  milk;  stir  well,  sweeten 
to  taste,  and  grate  a  little  nutmeg  on  top. 

Peptonized  Milk  Lemonade. — Take  a  glass  one-third  full  of 
cracked  ice;  squeeze  into  this  the  juice  of  a  lemon,  and  add  two  or 
three  teaspoonfuls  of  sugar  dissolved  in  water.  Fill  the  glass  with 
fresh  specially  peptonized  milk  and  stir  'well.  If  preferred,  equal 
parts  of  milk  and  of  an  effervescent  mineral  water  may  be  used.  Four 
the  water  on  the  lemon  juice  and  ice,  and  immediately  fill  the  glass 
with  milk. 

Peptonized  Milk  Gruel. — Mix  a  teaspoonful  of  wheat  flour,  ar- 
rowroot flour,  or  Robinson's  Barley  Flour  with  half  a  pint  of  cold 
water.  Boil  for  five  minutes,  stirring  constantly.  Add  one  pint  of 
cold  milk  and  strain  into  a  jar ;  add  the  usual  peptonizing  ingredients ; 
place  in  warm  water  (115°  F.)  for  twenty  minutes,  and  then  upon  ice. 

Junket,  or  Curds  and  Whey. — Take  a  half  pint  of  fresh  milk;  add 
one  teasponful  of  Fairchild's  Essence  of  Pepsin  and  stir,  just  sutifi- 
ciently  to  mix.  Pour  into  custard  cups,  and  let  it  stand  until  firmly 
curdled.  It  may  be  served  plain  or  with  sugar  and  grated  nutmeg. 
It  may  be  flavored  with  wine,  which  should  be  added  before  curdling 
takes  place. 

Junket  with  Egg. — Beat  one  egg  to  a  froth,  and  sweeten  with  two 
teaspoonfuls  of  white  sugar;  add  this  to  a  half -pint  of  warm  milk; 
and  then  add  one  teaspoonful  of  essence  of  pepsin  and  let  it  stand 
until  curdled. 

Cocoa  Junket. — Put  an  even  tablespoonful  of  any  good  cocoa  and 
two  teaspoonfuls  of  sugar  into  a  sauce-pan ;  scald  with  two  table- 
spoonfuls  of  boiling  water  and  rub  into  a  smooth  paste;  then  stir  in 
thoroughly  one-half  pint  of  fresh,  cool  milk;  heat  this  mixture  until 
it  is  lukewarm — not  over  100°  F. — then  add  one  teaspoonful  of  Fair- 
child's  Essence  of  Pepsin  and  stir  just  enough  to  mix;  pour  quickly 
into  small  cups  or  glasses,  and  let  it  stand  until  firmly  curdled,  when 
the  junket  is  ready  for  use.  It  may  be  placed  on  ice  and  eaten  cold ; 
as  a  dessert  it  may  be  served  with  whipped  cream. —  {Fairchild.) 


MILK  PREl'AliAriOyS  779 

Coffee  Junket. — Dissolve  two  teaspoonfuls  of  sugar  in  two  table- 
spoonfuls  of  clear,  strong  coffee ;  mix  this  thoroughly  with  one-half 
pint  of  fresh,  cool  milk;  add  a  teaspoonful  of  Fairehild's  Essence  of 
Pepsin  as  directed  above,  and  serve  in  the  same  way. 

Iodized  Junket. — Prescribe  a  saturated  solution  of  potassium  iodid 
and  also  a  bottle  of  essence  of  pepsin.  Take  one-half  teacui)ful  of 
milk  and  add  the  required  number  of  drops  of  the  iodid  solution. 
Heat  the  milk  luke-warm  and  add  two  or  three  teaspoonfuls  of  the 
pepsin  and  let  it  stand  until  curdled.  This  will  be  found  useful 
where  it  is  difficult  to  administer  the  iodid  by  ordinary  methods. 

Vanilla,  Bitter  Almond,  or  Strawberry  Junket. — Add  the  flavor- 
ing extract  to  the  cold  milk  and  then  prepare  in  the  usual  way.  One 
half  teaspoonful  of  vanilla  or  bitter  almond  extract  or  a  tablespoonful 
of  a  pure  concentrated  strawberr}^  syrup  should  be  allowed  to  a  half- 
pint  of  milk. 

Milk  Lemonade. — Take  two  ounces  of  sugar,  five  ounces  of  boiled 
milk,  one-half  lemon,  or  two  ounces  of  white  wine,  five  ounces  of  boil- 
ing water,  and  the  rind  of  half  a  lemon.  Pour  the  boiling  water  over 
the  peel  and  the  sugar;  allow  it  to  cool,  add  the  milk,  and  then  the 
lemon  juice  or  wine.     Strain  after  ten  minutes. 

Milk  Punch. — Shake  together  in  a  lemonade-shaker  a  glass  of  milk, 
a  tablespoonful  of  rum,  brandy,  or  good  old  whisky,  and  two  teaspoon- 
fuls of  sugar.  After  it  has  been  poured  into  a  glass  a  little  nutmeg 
may  be  grated  over  the  top. 

Milk  Porridge. — Mix  a  tablespoonful  of  flour  with  one-fourth  cup- 
ful of  cold  milk  and  stir  into  one-fourth  cupful  of  hot  milk ;  if  desired, 
add  two  raisins  cut  into  quarters.  Cook  over  boiling  water  for  one 
hour,  and  add  one-quarter  teaspoonful  of  salt  just  before  serving. — 
{Drexel  Institute.) 

Whey. — Take  a  half-pint  of  fresh  milk  heated  lukewarm  (115°  F. ), 
add  one  tablespoonful  of  essence  of  pepsin,  and  stir  just  enough  to 
mix.  When  this  is  firmly  coagulated,  beat  up  with  a  fork  until  the 
curd  is  finely  divided  and  then  strain.  For  flavoring  purposes  lemon 
juice  or  sherrj^  wine  may  be  added. 

Grape  Juice  Whey. — Make  whey  as  in  the  above  recipe.  To  this 
add  the  juice  of  an  orange  and  a  quarter  of  a  pint  of  grape  juice. 
Strain  again  if  necessary.  This  may  be  served  hot  or  on  cracked  ice. 
It  may  be  sweetened  if  desired. 

Cream=of=tartar  Whey. — Add  a  heaping  teaspoonful  of  cream  of 
tartar  to  a  pint  of  boiling  water.  Strain,  sweeten  to  taste,  and  serve 
cold. —  (Pavy.) 

Wine  Whey. — Cook  together  a  cupful  of  milk  and  half  a  cupful  of 
sherry  wine.  As  soon  as  the  curd  separates,  strain  and  sweeten. 
This  may  be  eaten  hot  or  cold. 

Lemon  Whey. — This  is  made  in  the  same  way  as  the  foregoing 
recipe,  using  three  tablespoonfuls  of  lemon  juice  instead  of  the  wine. 


780  RECIPES 

Kumiss  No.  i. — Take  a  quart  of  skim  milk,  one-fifth  of  a  cake  of 
yeast,  and  two  tablespoonfuls  of  sugar.  Heat  the  milk.  Dissolve  the 
yeast  in  a  little  water  and  mix  it  with  the  sugar  and  lukewarm  milk. 
Pour  the  mixture  into  strong  bottles,  stopper  them  tightly  with  new 
corks,  and  tie  down  the  corks  with  stout  twine.  Shake  the  bottles 
well  and  place  in  a  refrigerator ;  this  will  allow  the  mixture  to  ferment 
slowly.  After  three  days  lay  the  bottles  on  their  sides,  turning  them 
occasionally.  Five  days  are  required  to  complete  the  fermentation; 
the  kumiss  is  then  at  its  best. —  {Drexel  Institute.) 

Kumiss  No.  2. — Pour  into  wired  bottles  one  quart  of  fresh  milk,, 
half  an  ounce  of  sugar,  a  piece  of  fresh  yeast  cake  half  an  inch 
square,  and  keep  at  a  temperature  between  60°  and  70°  F.  for  one 
week,  shaking  five  or  six  times  a  day;  then  put  upon  ice. —  (Holt.) 

Kefir  With  Kefilac  Tablets. — Pour  into  a  well  cleaned  quart  bottle 
one  pint  of  pure  milk,  which  has  been  boiled  and  cooled  to  lukewarm 
temperature. 

Put  one  Kefilac  tablet,  crushed,  into  the  bottle  and  shake  thoroughly 
until  dissolved.     Cork  tight  with  a  good,  clean  cork. 

Place  the  bottle  at  a  temperature  of  the  ordinary  living  room  (70°- 
75°),  lying  on  its  side.  As  fermentation  advances,  a  curd  will  be 
observed  forming  in  the  bottle.  Shake  thoroughh^  four  to  five  times 
a  day  until  ready  for  use.  This  curd  re-forms  when  the  bottle  is  at 
rest,  and  should  be  shaken  thoroughly  each  time  the  contents  are 
used. 

After  the  first  day  a  slightly  sour,  after  the  second  day  medium 
strong,  sweetish  sour,  and  after  the  third  day,  a  strong,  sour  tasting, 
lightly  foaming  kefir  is  produced.  One  day  old  kefir  is  slightly  lax- 
ative.    For  general  use,  forty-eight-hour  kefir  is  recommended. 

If  the  kefir  does  not  turn  over  right,  as  sometimes  happens,  when 
impure  milk  is  used  or  whenever  changeable  weather  prevails  in  the 
summer,  it  is  necessary  to  cleanse  the  bottle  thoroughly,  and  boil  it  in 
a  soda  solution  for  five  minutes  before  using  again. 

If  a  larger  quantity  of  kefir  than  one  pint  is  to  be  made,  one  tablet 
should  be  used  for  each  extra  pint,  and  this  proportion  continued.  It 
should  be  carefully  noted  that  the  bottle  should  be  twice  the  size  of 
its  contents,  in  order  to  provide  for  fermentation.  After  fermentation 
is  complete,  which  is  about  forty-eight  hours,  kefir  remains  good  for 
several  days,  if  kept  on  ice. 

Kefir  may  be  used  freely,  and  to  the  same  extent  as  ordinary  milk. 
From  one  pint  to  three  quarts  per  day,  according  to  requirements  of 
the  individual. 

Milk  Mixture. — This  is  made  of  cream,  two  parts;  milk,  one 
part;  lime  water,  two  parts;  sugar  water,  three  parts  (seventeen 
and  three-fourths  drams  of  milk  sugar  to  a  pint  of  water). —  (A.  V. 
Meigs. ) 

Milk=and=cinnamon  Drink. — Add  a  small  amount  of  cinnamon  to 


EGGS  781 

the  desired  quantity  of  milk  and  boil  it.  Sweeten  with  sugar  and 
add  brandy  if  desired. —  (Ringer.) 

Albuminized  Milk. — Shake  in  a  covered  jar  or  lemonade-shaker  a 
cupful  of  milk,  a  tablespoonful  of  lime-water,  and  the  white  of  an 
egg.     Sweeten,  flavor  as  desired,  and  serve  at  once. 

Milk=and=cereal  Waters. — A  most  valuable  method  of  preparing- 
milk  for  invalids  with  whom  it  disagrees  is  to  mix  equal  parts  of  milk 
and  thoroughly  cooked  barley,  rice,  oatmeal  or  arrowroot  water  and 
boil  them  together  for  ten  minutes.  This  may  be  served  plain,  or 
flavored  by  cooking  with  it  a  cut-up  raisin,  a  sprig  of  mace,  or  a 
piece  of  stick  cinnamon,  which  should  be  strained  out  before  serving. 

Irish  Moss  and  Milk. — Soak  about  two  tablespoonfuls  of  Irish 
moss  for  five  minutes  and  wash  thoroughly  in  cold  water.  Add  to  a 
cupful  of  milk  and  soak  for  half  an  hour ;  then  heat  slowly,  stirring 
constantl3%  and  then  boil  for  ten  minutes,  preferably  in  a  double 
boiler;  strain,  and  pour  into  cups  and  cool.  This  may  be  served  while 
hot,  and  may  be  rendered  more  nutritious  by  the  addition  of  the  white 
of  an  egg  stirred  into  it  just  before  serving. 

Egg  and  Buttermilk  Mixture. — Lightly  beat  the  white  of  one  egg 
and  from  one  to  four  ounces  of  cream.  Pour  into  a  glass  and  fill  with 
fresh  buttermilk.     Stir  well. 

Milk  with  Other  Diluents. — Milk  may  be  diluted  with  advantage 
in  many  cases  by  adding  lime  water,  or  Vichy,  Apollinaris  or  some 
other  sparkling  table  water.  From  one-half  to  one-eighth  the  total 
volume  may  be  added. 

EGGS 

Eggs  are  exceedingly  valuable  as  food  for  invalids.  They  should 
always  be  fresh.  When  received  they  should  be  washed  and  then 
placed  in  a  cool  place.  They  should  not  be  kept  with  any  article  of 
food  having  an  odor,  as  they  absorb  such  odors  and  the  taste  is  thereby 
impaired.  Stale  eggs  will  not  sink,  and  if  held  to  a  bright  light  they 
show  a  dark  spot.  The  yolk  of  an  egg  that  has  been  broken  may 
be  kept  fresh  by  placing  it  (unbroken)  in  a  cupful  of  cold  water. 
This  should  be  set  in  a  cool  place.  This  will  keep  it  fresh  for  twenty- 
four  hours  or  more. 

Eggs  and  all  other  albuminous  foods  should  be  cooked  at  as  low 
temperature  as  possible,  in  order  to  avoid  rendering  them  tough. 

Eggs  are  best  cooked  in  the  shell  as  follows : 

Soft-cooked  Eggs. — Place  in  a  pint  of  boiling  water,  remove  from  the 
fire,  and  allow  to  stand  for  eight  or  ten  minutes.  If  the  egg  is  very 
cold  to  start  with,  it  will  take  a  little  longer. 

Hard-cooked  Eggs. — Place  in  water,  bring  to  a  boil,  and  then  set  on 
the  back  part  of  the  stove  for  twenty  minutes. 

Eggs  should  be  served  as  soon  as  cooked,  and  the  dishes  should  be 
warmed  and  ready. 


782  RECIPES 

EGGS  AND  MILE 

Rules  for  Custards. — The  eggs  should  be  thoroughly  mixed  but 
not  beaten  light,  the  sugar  and  salt  added  to  these,  and  the  hot  milk 
added  slowly.  Custards  must  be  cooked  over  moderate  heat ;  if  a 
custard  curdles,  put  it  in  a  pan  of  cold  water  and  beat  until  smooth. 
Custards  should  always  be  strained. —  {Drexel  Institute.) 

Soft  Custard. — Take  a  pint  of  milk,  the  yolks  of  two  eggs,  two  table- 
spoonfuls  of  sugar,  and  a  pinch  of  salt.  j\Iix  all  except  the  milk  in 
a  bowl.  Heat  the  milk  to  the  boiling-point  and  add  constantly.  As 
soon  as  mixed,  pour  into  the  saucepan  in  which  the  milk  has  been 
heated  and  cook  from  three  to  five  minutes,  stirring  constantly  until 
it  thickens.  Strain,  and  pour  into  a  cold  bowl,  and  flavor  with  from 
half  to  one  teaspoonful  of  vanilla,  a  teaspoonful  or  more  of  sherrj^,  or 
other  flavoring  material  as  desired.  Custards  may  be  cooked  to  ad- 
vantage in  a  double  boiler. 

Chocolate  Custard. — I\Ielt  half  an  ounce  of  Baker's  chocolate  and 
add  to  the  milk,  and  proceed  as  above. 

Steamed  Custard. — Mix  the  above,  using  the  whole  eggs  instead  of 
the  yolks.  Strain,  pour  into  cups,  and  steam  over  boiling  water  until 
firm. 

Baked  Custard. — Proceed  as  above,  but  pour  the  custard  into  bak- 
ing-cups. Place  the  cups  in  a  deep  baking-pan  and  fill  the  pan 
nearly  as  high  as  the  cups  with  boiling  water.  Place  in  the  oven  and 
bake  twenty  minutes  or  longer,  according  to  the  size  of  the  cup. 
AVhen  done  a  clean  knife  thrust  into  the  custard  comes  out  clean;  if 
it  is  not  done,  it  comes  out  covered  with  milk. 

Egg  Pudding. — Beat  well  the  yolk  of  one  egg,  add  half  cupful  of 
milk,  a  spoonful  of  sugar  and  a  little  vanilla  extract;  then  beat  the 
white  of  the  egg  very  stiff  and  stir  in  lightly. 

Apple  Snow. — Apple  sauce  sweetened  and  beaten  up  with  white  of 
egg,  whipped  cream  on  top.     Flavor  with  vanilla. 

MEATS 

General  Rules  for  Preparing  Meat. — ]Meat  must  be  weighed, 
trimmed,  and  wiped  with  a  damp  cloth.  It  should  be  removed  imme- 
diately from  the  paper  in  M^hich  it  was  wrapped  and  placed  in  a  cool 
place.  Only  tender  cuts  of  meat  should  be  broiled,  pan-broiled,  or 
roasted.  AVhen  meat  is  to  be  cooked  by  any  of  these  methods,  it  should 
first  be  seared,  and  then  the  temperature  slightly  lowered ;  by  searing, 
the  albumin  on  the  outer  surface  of  the  meat  is  hardened  and  the 
meat  is  thus  cooked  in  its  own  juices. 

Tough  meat  should  be  cooked  in  water;  boiling  water  hardens  the 
albumin  on  the  outer  surface  of  the  meat  and  prevents  the  juices  from 
escaping.  Meat  should  be  put  in  boiling  water  and  the  water  allowed 
to  boil  for  ten  or  fifteen  minutes ;  then  the  cooking  should  be  allowed 


MEATS  783 

to  proceed  at  a  low  temperature  until  the  meat  is  tender.  If  the 
water  bubbles,  it  is  too  hot.  Cooked  in  this  way  tough  meat  will 
become  tender.  The  time  required  for  roasting  or  cooking  in  water 
varies  with  the  weight  and  quality  of  the  meat. 

For  roasts  weighing  less  than  8  pounds  allow  ten  minutes  to  the 
pound  and  ten  minutes  extra ;  for  those  weighing  from  8  to  12  pounds, 
allow  twelve  minutes  to  the  pound  and  twelve  minutes  extra;  for 
those  Aveighing  over  12  pounds,  allow  fifteen  minutes  to  the  pound 
and  fifteen  minutes  extra.  For  meat  weighing  less  than  10  pounds, 
to  be  cooked  in  water,  allow  twenty  minutes  to  the  pound  and  twenty 
minutes  extra. 

The  time  required  for  broiling  meat  varies  with  the  thickness  of  the 
meat. 

•Stock  and  broth  are  prepared  by  prolonged  soaking  of  the  meat  in 
cold  water  and  then  cooking  it  at  a  low  temperature  for  several  hours, 
allowing  it  to  cool  uncovered.  The  meat  that  remains  after  straining 
may  be  utilized  in  various  ways,  adding  a  little  fresh  meat  to  give  it 
flavor. 

The  fat  must  not  be  removed  from  stock  or  broth,  for  it  excludes 
the  air  and  prevents  decomposition.  It  must,  however,  be  entirely 
removed  before  the  stock  or  broth  is  used ;  this  fat  may  be  used  in 
place  of  drippings.  The  trimmings  of  fat  from  meat  should  be  clari- 
fied. Small  globules  of  fat  may  be  removed  from  cold  broth  with  a 
cloth  that  has  been  dipped  in  boiling  Mater  and  then  wrung  dry. 
Fat  may  be  removed  from  hot  broth  by  means  of  tissue-paper  or  a  slice 
of  bread. 

Cooking  Tender  Meats. — Roasting. — Skewer  the  meat  into  shape. 
Place  it  on  a  rack  in  a  meat  pan,  into  the  bottom  of  which  pieces  of 
fat  from  the  meat  have  been  placed.  Put  in  a  hot  oven  on  the  grate 
for  ten  minutes,  to  sear  the  meat.  If  desired  it  may  be  seasoned  with 
salt  and  pepper.  Then  remove  to  the  floor  of  the  oven  and  baste 
every  ten  minutes  until  it  is  done. 

Broiling. — Remove  extra  fat  from  the  meat  and  grease  the  broiler 
with  a  part  of  the  fat.  Broil  over  a  clear  fire;  sear,  and  then  turn 
every  ten  seconds.  Chops  one  inch  thick  should  be  cooked  for  five 
minutes.  A  steak  two  inches  thick  should  be  cooked  for  ten  minutes. 
Season  and  serve  on  a  hot  platter. 

Pan-hroiling. — Remove  all  the  fat  from  the  meat.  Heat  a  frjang- 
pan  very  hot,  but  use  no  fat.  Sear  the  meat  on  both  sides,  and  then 
cook  more  slowly  until  it  is  done.  Stand  chops  up  on  their  edges  to 
broAvn.  Keep  the  pan  free  from  fat.  The  time  required  for  pan- 
broiling  is  the  same  as  that  required  for  broiling. —  (Drexel  Institute.) 


784  RECIPES 


GENERAL  RULES  FOR  SOUPS 

Both  meats  and  vegetables  should  be  cut  into  small  pieces.  The 
soup  should  be  started  with  cold  water  poured  over  the  meats  and 
the  heat  applied  gradually  and  the  soup  allowed  to  simmer,  in  order 
to  dissolve  as  much  of  the  nutriment  as  possible.  If  heated  rapidly 
the  albumin  in  the  meat  coag-ulates,  and  little  but  the  extractives  passes 
into  the  soup.  The  vegetables  are  added  when  the  soup  is  nearly 
done. 

Remove  the  fat  by  skimming,  by  using  blotting-paper,  by  straining 
through  a  cloth  wet  in  cold  water,  or,  best  of  all,  by  cooling  the  soup 
when  all  the  "fat  rises  to  the  top,  when  it  can  be  easily  removed. 

Clear  soups  may  be  rendered  more  nutritious  by  the  addition  of 
sago  or  of  some  cereal,  as  barley  or  rice.  These  may  also  be  added 
with  advantage  to  many  thick  soups. 

Soups  should  always  be  served  hot.  Soup  jellies  are  served  cold, 
and  in  hot  weather  may  be  substituted  for  warm  soups. 

Soups  maj'  also  be  made  from  soup  stocks,  which  may  be  prepared 
in  any  quantity  and  kept  for  several  days.  Stocks  may  be  made  from 
any  meat.  Those  made  from  chicken  or  veal  are  light  in  color,  and 
those  from  beef  and  mutton  somewhat  darker.  Stocks  may  also  be 
made  by  using  the  bones  from  any  kind  of  meats. 

Soup  Stock. — To  make  stock,  use  chicken  or  several  pounds  of 
bones  with  some  meat  attached,  or  a  pound  of  lean  meat  and  one 
quart  of  water.  Cut-up  vegetables  may  be  added  as  desired.  For 
flavoring  add  a  sprig  of  parsley  and  of  celery,  a  peppercorn,  a  small 
onion,  and  a  scant  teaspoonful  of  salt.  Any  of  the  flavoring  vegetables 
may  be  omitted  as  desired  or  others  added.  The  meat  should  simmer 
for  several  hours,  until  but  half  the  quantity  of  water  remains.  Then 
add  the  other  ingredients,  simmer  half  an  hour  longer,  strain  and 
cool.     Remove  the  fat. 

Soup  Stock  from  Beef  Extract. — Cook  the  other  ingredients,  except 
the  salt,  as  given  above,  for  half  an  hour,  using  a  quart  of  water. 
Then  add  a  teaspoonful  of  beef  extract  and  a  quarter  of  a  teaspoonful 
of  salt. 

Soup  from  Stock. — Rice,  tapioca,  or  whatever  is  desired  is  cooked 
and  the  stock  added,  with  additional  seasoning  as  thought  necessary. 
Cream,  yolks  of  eggs,  Irish  moss,  cornstarch  or  arrowroot  may  be 
added  to  render  the  soup  more  nutritious. 

Chicken  Broth. — Take  one  pound  of  chicken  and  a  pint  of  cold 
water.  Clean  the  fowl,  cut  it  into  pieces,  and  remove  the  skin.  Sep- 
arate the  meat  from  the  bone  and  chop  the  meat  very  fine.  Place 
with  the  bones — if  large,  they  should  be  broken — in  the  water  and 
soak  for  an  hour.  Cook  over  hot  water  for  four  or  five  hours  at  a 
temperature  of  190°  F.     Strain  and  add  salt.     Water  must  be  added 


GENERAL  RULES  FOR  SOUPS  785 

from  time  to  time  to  keep  the  quantity  up  to  a  pint.  Remove  the  fat. 
If  the  broth  is  to  be  reheated  use  a  double  boiler. 

Sweetbread  Soup. — Tlie  sweetbread  is  soaked  in  cold  water  for  one 
hour,  the  water  being  renewed  frequently  during-  this  time.  It  is 
then  boiled  for  one  hour  in  slightly  salted  water  or  beef  broth,  to 
which  one  may  add  one  teaspoonful  of  julienne  to  improve  the  taste. 
After  it  is  soft  the  sweetbread  is  taken  out  of  the  beef  broth  and  all 
blood-vessels  and  skin  are  removed.  It  may  now  be  cut  into  pieces 
the  size  of  a  walnut  and  put  on  a  plate,  over  which  the  beef  broth  is 
poured,  or  the  sweetbread  may  be  forced  through  a  sieve,  beef  broth 
poured  over  this,  and  the  whole  put  on  the  fire  again  until  it  boils, 
after  which  the  soup  may  be  served.  This  latter  process  is  to  be 
recommended  in  the  case  of  dyspeptics.  —  (Wegele.) 

Meat  Broth  (Beef,  Veal,  Mutton,  or  Chicken). — Cover  one  pound 
of  chopped  lean  meat  with  one  pint  of  water  and  allow  it  to  stand  for 
from  four  to  six  hours.  Then  cook  over  a  slow  fire  for  an  hour  until 
reduced  to  half  the  quantity.     Cool,  skim,  pour  into  jar  and  strain. 

Veal  Broth. — Pour  a  pint  of  water  on  a  half-pound  of  finely 
chopped  lean  veal  and  allow  it  to  stand  for  three  hours.  Boil  for  a 
few  minutes,  strain,  and  season  with  salt. 

Clam  or  Oyster  Juice. — Cut  the  clams  or  oysters  into  pieces  and 
heat  for  a  few  minutes  in  their  juice.  Strain  through  muslin  and 
serve  while  hot.  In  straining  great  care  must  be  taken  that  sand  does 
not  pass  through  the  muslin.  The  juices  should  be  diluted  and  may 
be  frozen. —  (Drexel  Institute.) 

Clam  Broth. — Wash  three  large  clams  very  thoroughly,  using  a 
brush  for  the  purpose.  Place  in  a  kettle  with  half  a  cupful  of 
cold  water.  Heat  over  the  fire;  as  soon  as  the  shells  open  the  broth 
is  done.  Strain  through  muslin,  season,  and  serve. —  {Drexel  Insti- 
tute.) 

Mutton  Broth  with  Vegetables. — Allow  one  pound  of  neck  mut- 
ton to  each  pint  of  water;  add  carrots,  turnips,  onions  and  barley; 
let  all  simmer  together  for  three  hours. 

Mutton  Broth  without  Meat. — Cook  two  ''shank-ends"  in  a  pint 
of  cold  water,  and  vegetables  as  directed  in  the  foregoing  recipe ;  sim- 
mer for  three  hours  and  strain. 

Beef  Tea  No.  i. — Cut  up  a  pound  of  lean  beef  into  pieces  the  size 
of  dice;  put  it  into  a  covered  jar  with  two  pints  of  cold  water  and  a 
pinch  of  salt.  Let  it  warm  gradually  and  simmer  for  two  hours,  care 
being  taken  that  it  does  not  at  any  time  reach  the  boiling-point. — 
(Yeo.) 

Beef  Tea  No.  2. — Put  a  pound  of  finely  mixed  beef  with  a  pint  of 
cold  water  into  a  suitable  vessel.  Let  it  stand  for  an  hour,  stirring 
occasionally.  Put  the  vessel  containing  the  beef  into  a  saucepan  of 
water,  place  it  over  the  fire,  and  allow  the  water  to  heat  gently  for  an 
hour  (or  the  vessel  containing  the  beef  tea  may  be  put  into  an  ordi- 

50 


786  KECIPES 

nary  oven  for  an  hour).  Pass  the  beef  tea  through  a  strainer.  A 
tine  sediment  appears  in  the  fiuid,  and  this  should  be  drunk  with  the 
liquid.  Flavor  with  salt.  At  no  time  should  beef  extract  be  ex- 
posed to  a  temperature  of  more  than  170°  F. —  {Pavij.) 

Beef  Tea  No.  3. — Chop  line  a  pound  of  beef  free  from  fat,  tendons, 
etc.,  and  digest  with  a  pint  of  cold  water  for  two  hours.  Let  it  sim- 
mer on  the  stove  for  three  hours  at  a  temperature  never  above  160°  F. 
Replace  the  water  lost  by  evaporation  by  adding  cold  water,  so  that 
a  pint  of  beef  tea  shall  represent  a  pound  of  beef.  Strain  and  care- 
fully express  all  fluid  from  the  beef. —  (Bartholow.) 

Beef  Tea  with  Oatmeal. — Mix  thoroughly  one  tablespoonful  of 
groats  with  two  of  cold  water ;  add  to  this  a  pint  of  boiling  beef  tea. 
Boil  for  ten  minutes,  stirring  constantly,  and  strain  through  a  coarse 
sieve. —  (Yeo.) 

Beef  Tea,  Flavored. — Beef  tea  may  be  flavored  agreeably  by  boil- 
ing in  it  a  pinch  of  mixed  herbs,  a  bay-leaf,  or  a  bit  of  onion,  carrot, 
turnip,  or  celery  and  a  fcAV  peppercorns.  The  roots  should  either  be 
chopped  small  or  be  scraped  to  a  pulp  before  being  added  to  the 
broth.— (Yeo.) 

Beef  Juice. — Broil  quickly  pieces  of  the  round  or  sirloin  of  a  size 
to  tit  the  opening  in  a  lemon  squeezer.  Both  sides  of  the  beef  should 
be  scorched  quickly  to  prevent  the  escape  of  the  juices,  but  the  in- 
terior should  not  be  fully  cooked.  As  soon  as  they  are  ready  the 
pieces  of  meat  should  be  squeezed  in  a  lemon  squeezer  previously 
heated  by  being  dipped  in  hot  water.  As  it  drips  the-  juice  should  be 
received  into  a  hot  wineglass;  it  should  be  seasoned  to  the  taste 
with  salt  and  a  little  Cayenne  pepper,  and  taken  while  hot. —  {Bar- 
iholow.) 

Cold  Beef  Juice. — Cover  one  pound  of  tinely  chopped  lean  beef 
with  eight  ounces  of  cold  water  and  allow  it  to  stand  for  eight  or  ten 
hours.  Squeeze  out  the  juice  by  means  of  a  muslin  bag ;  season  with 
salt  or  sherry  wine  and  drink  cold  .or  slightly  warmed.  It  may  be 
added  to  milk,  care  being  taken  that  the  milk  be  not  too  hot  before  the 
juice  is  added. 

Iced  Meat  Extract. — Cut  into  pieces  the  size  of  a  hand  one  kilo  of 
fresh  beef;  wrap  in  a  coarse,  lattice-like  linen  bag,  put  under  a  lever 
press,  and  press  slowly.  The  juice  should  be  caught  in  a  porcelain 
dish.  This  is  done  best  by  a  druggist.  By  this  method  about  500 
gm.  of  juice  are  obtained.  The  juice  is  mixed  with  250  gm.  of  sugar, 
200  gm.  of  freshly  expressed  lemon  juice  (this  last  is  best  omitted  in 
the  case  of  dyspeptics),  and  20  gm.  of  cognac  containing  vanilla  ex- 
tract ;  stir  in  well  the  yolks  of  three  eggs ;  the  entire  mixture  is  then 
placed  in  a  freezer. —  {v.  Ziemssen.) 

Raw=meat  Juice. — Add  to  finely  minced  rump  steak  cold  water,  in 
the  proportion  of  one  part  of  water  to  four  parts  of  meat.  Stir  well 
together,  and  allow  it  to  stand  for  half  an  hour.     Forcibly  express 


GENERAL  NILES  FOR  t^Oi  Fi^  787 

the  jiiiee  through  muslin,  twisting  it  to  get  the  best  results. — 
{Cheadlc.) 

Succus  Carnis  (Meat  Juice).— Cut  up  the  meat  into  small  bits, 
arrange  in  layers  separated  from  one  another  by  coarse  linen,  and 
then  place  in  a  powerful  press.  From  each  kilogram  of  meat  about 
230  gm.  of  a  blood-red  juice  are  obtained.  This  contains  about  6  per 
cent,  of  albuminates.  Its  taste  is  similar  to  that  of  raw  meat ;  its 
flavor  may  be  improved  by  the  addition  of  salt  and  beef  tea  not  hot 
enough  to  coagulate  the  albumin. —  (Pettenkoffer  and  Voit.) 

Leube-Rosenthal  Meat  Solution. — Chop  1  kilo  of  beef  into  fine 
pieces,  mixing  with  it  a  liter  of  water  and  add  20  grams  of  ])ure 
hydrochloric  acid  and  boil  mixture  ten  to  fifteen  hours  in  a  Papin  pot. 
The  mass  which  is  obtained  is  crushed,  boiled  fifteen  hours  longer, 
neutralized  with  pure  sodium  carbonate  and  evaporated  to  a  mush. 

Beef  Essence. — Chop  up  very  fine  a  pound  of  lean  beef  free  from 
fat  and  skin ;  add  a  litle  salt,  and  put  into  an  earthen  jar  with  a  lid ; 
fasten  up -the  edges  with  a  thick  paste,  such  as  is  used  for  roasting 
venison  in,  and  place  the  jar  in  the  oven  for  three  or  four  hours. 
Strain  through  a  coarse  sieve,  and  give  the  patient  two  or  three  table- 
spoonfuls  at  a  time. —  (Yeo.) 

American  Bouillon  (American  Broth). — Place  in  a  tin  vessel  that 
can  be  sealed  hermetically  alternate  layers  of  tinely  minced  meat  and 
vegetables.  Seal  it,  and  keep  it  heated  in  a  w^ater  bath  (bain  marie) 
for  six  or  seven  hours,  and  then  express  the  broth. —  (Yeo.) 

Bottle  Bouillon. — Cut  beef,  free  from  fat,  into  squares.  Place 
these  in  a  stoppered  bottle,  put  the  bottle  in  a  basin,  of  warm  water, 
heat  slowly,  and  boil  for  twenty  minutes.  There  will  be  about  an 
ounce  of  yellowish  or  brownish  fluid  for  each  three-quarters  of  a 
pound  of  meat  used.  The  flavor  is  that  of  concentrated  bouillon. — 
{V/felmann.) 

Peptonized  Oysters. — To  half  a  dozen  oysters  with  their  juice 
add  half  a  pint  of  water  and  boil  for  a  few  minutes.  Pour  off  the 
broth  and  set  it  aside.  Mince  the  oysters,  and  with  the  aid  of  a 
potato-masher  reduce  to  the  consistence  of  a  paste.  Place  this  with 
the  broth  in  a  glass  jar  and  add  flfteen  grains  each  of  extract  of 
pancreas  and  of  bicarbonate  of  soda  and  mix.  Allow  this  to  stand 
in  hot  water  (115°  F.)  for  one  and  one-half  hours.  Pour  into  a 
saucepan  and  add  half  a  pint  of  milk ;  heat  over  a  slow  Are  to  boiHng- 
point.  Flavor  w'ith  salt  and  pepper  and  serve  hot.  Let  the  heating 
be  done  gradually,  and  be  careful  to  bring  the  mixture  to  a  boil  before 
taking  it  from  the  fire. —  {Fairchild.) 

Peptonized  Beef. — Cover  one-fourth  of  a  pound  of  finely  minced 
lean  beef  (or  beef  and  chicken  mixed)  with  half  a  pint  of  cold  water. 
Cook  over  a  slow  fire  until  it  has  boiled  for  a  few  minutes,  stirring 
constantly.  Pour  of¥  the  broth  and  rub  or  pound  the  meat  to  a 
paste.     Put  meat  and  broth  and  half  a  pint  of  cold  water  in  a  glass 


788  RECIPES 

jar,  and  add  twenty  grains  of  extract  of  pancreas  and  fifteen  grains 
of  bicarbonate  of  soda.  Mix  well  and  keep  in  a  warm  place — at  about 
110°-115°  F. — or  place  it  in  warm  water  and  allow  it  to  stand  three 
hours,  stirring  or  shaking  occasionally.  Boil  quickly ;  strain  or  clarify 
with  the  white  of  an  egg  and  season  with  salt  and  pepper.  If  de- 
sired, it  need  not  be  strauied,  as  the  small  particles  of  meat  are  usuall}^ 
easily  digested.  Cereals  may  be  added,  boiling  with  half  the  amount 
of  water  previously  directed,  and  mixing  all  together  before  pepton- 
izing. At  the  end  of  three  hours  the  mixture  must  be  boiled  or  it  will 
spoil. —  ( Fa  ir  child. ) 

METHODS  OF  PREPARING  RAW  BEEF 

Bleat  given  raw  should  always  be  perfectly  fresh  and  very  finely 
divided.  Scrape  the  meat  with  a  sharp  knife,  which  will  separate  the 
coarser  fibers.  If  the  resulting  mass  is  stringy,  pass  through  a  fine 
sieve.  This  may  be  seasoned  with  salt  and  pepper,  and  served  on 
toast,  crackers,  or  bread  and  butter.  It  may  be  rolled  into  small 
balls  and  swallowed.  These  may  be  flavored  as  desired.  They  may 
also  be  slightly  browned  by  rolling  about  rapidly  in  a  hot  saucepan, 
care  being  taken  not  to  change  any  but  the  outside  of  the  ball,  and 
that  but  slightly.  Scraped  beef  may  be  served  as  a  liquid  or  semi- 
solid food.  Blix  it  with  an  equal  quantity  of  cold  water  until  it  is 
quite  smooth.  Place  in  a  double  boiler  and  cook  until  thoroughly 
heated,  stirring  constantly.  Add  a  little  salt  and  pepper  and  serve 
at  once.     This  may  be  made  thicker  by  adding  less  water. 

Raw  Meat  with  Milk  and  Sugar. — Scrape  half  a  pound  of  rump 
steak  Avith  a  knife  until  all  the  pulp  is  removed ;  sweeten  with  sugar, 
breaking  the  lumps  of  sugar  with  the  meat  in  a  basin  with  a  small 
wooden  spoon.  Add  slowly  as  much  milk  as  will  make  it  about  the 
thickness  of  arrowroot ;  flavor  w'ith  brandy.  If  any  fiber  of  the  meat 
remains,  strain  through  a  gravy  strainer.  The  mixture  should  be  per- 
fectly smooth. —  ( Ringer. ) 

Raw=beef  Soup. — This  is  made  by  chopping  up  one  pound  of  raw 
beef  and  placing  it  in  a  bottle  with  one  pint  of  water  and  five  drops  of 
strong  hj^drochloric  acid.  This  mixture  is  allowed  to  stand  on  the 
ice  overnight,  and  in  the  morning  the  bottle  is  placed  in  a  pan  of 
water  at  110°  F.,  and  kept  at  about  this  temperature  for  two  hours, 
it  is  then  placed  in  a  stout  cloth  and  strained  until  the  mass  that  re- 
mains is  almost  dry.  The  filtrate  is  given  in  three  portions  daily. 
If  the  taste  of  the  raw  meat  is  objectionable,  the  meat  may  quickly 
be  roasted  on  one  side  and  the  process  completed  in  the  manner 
previously  described. —  {Weir  Mitchell.) 

Egg  Gruel.— Take  one  cupful  of  hot  beef  broth  made  with  "Soluble 
Beef,"  one  Qg^,  and  one-half  teaspoonful  of  salt.  Beat  the  white  and 
the  yolk  of  the  egg  separately ;  add  the  hot  beef  broth  gradually  to  the 


MEAT  JELLIES  ^Y1T^0UT  GELATIN  789 

yolk,  stirring  continually.  "Whip  the  white  to  a  stiff,  dry  froth  with 
the  salt,  and  beat  it  into  the  hot  broth.  Return  to  the  double  boiler 
and  reheat.     Serve  very  hot. 

Barley  Gruel  with  Beef  Extract. — One-half  teaspoonful  of  "Solu- 
ble Beef,"  two  eupfuls  of  hot  water,  one  tablespoonful  of  barley 
flour,  one  saltspoonful  of  salt.  Dissolve  the  beef  in  the  hot  water, 
and  mix  the  flour  and  salt  together  with  a  little  cold  water.  Pour  the 
boiling  stock  on  the  flour  and  cook  for  ten  minutes.  Strain  and  serve 
very  hot. 

Beef  Broth  with  Poached  Eggs. — Prepare  the  broth  in  the  propor- 
tion of  half  a  teaspoonful  of  "Soluble  Beef"  to  one  cupful  of  hot 
water  and  add  a  poached  egg. 

A  Nutritive  Drink  for  Delicate  Women  and  Children. — This  is 
made  by  mixing  one-fourth  to  one-half  teaspoonful  of  ' '  Soluble  Beef, ' ' 
five  ounces  of  boiling  M-ater,  and  one-half  ounce  of  cream ;  season  with 
salt  and  pepper  to  suit  the  taste. 

Beef  Broth  with  Grain. — Take  one  teaspoonful  of  "Soluble  Beef," 
one  quart  of  water,  one  tablespoonful  of  rice,  and  salt  to  taste.  Dis- 
solve the  "Soluble  Beef"  in  the  hot  water,  and  add  the  well-washed 
rice.  Simmer  slowly  until  dissolved  and  absorbed  by  the  rice,  adding 
more  beef  broth  if  too  much  boils  away.  If  not  entireh'  dissolved, 
the  broth  should  be  strained  before  using. 

Beef=tea  Egg=nog. — This  requires  one-eighth  teaspoonful  of  "Sol- 
uble Beef,"  one-half  cupful  of  hot  water,  one  tablespoonful  of  brandy, 
and  a  pinch  of  salt.  Beat  the  egg  slightly,  and  add  the  salt  and 
sugar.  Dissolve  the  "Soluble  Beef"  in  the  hot  water,  add  to  the  egg, 
and  strain.     ]Mix  thoroughly,  adding  wine,  and  serve. 

MEAT  JELLIES  WITHOUT  GELATIN 

Chicken  Jelly. — Half  a  grown  chicken  should  be  well  pounded, 
and  boiled  in  one  quart  of  water  for  two  hours  until  only  a  pint  re- 
mains ;  season  and  strain.  Serve  hot  or  place  on  ice,  where  it  will 
"jell." 

Veal=bone  Jelly. — Place  ten  pounds  of  veal  bones  and  ten  quarts 
of  water  or  weak  bouillon  over  the  fire  and  bring  to  just  a  boil.  Skim 
and  add  two  pounds  of  barley  and  a  little  salt.  Simmer  for  five  or 
six  hours  and  then  strain.  If  too  thick,  dilute,  before  serving,  with 
Jbouillon.     Stir  in  the  yolk  of  an  egg  in  a  cup  and  serve. 

Meat  Jelly. — This  is  made  by  cooking  good  boneless,  lean  beef  in  a 
water  bath  with  a  little  water  for  sixteen  hours  or  until  it  becomes 
gelatinized.  Of  the  artificial  preparations  on  the  market  for  making 
bouillon,  the  most  reliable  is  Liebig's  Extract  of  Meat  (10:250  gm.) 
or  Cibil's  Bouillon  (1  teaspoonful  to  250  gm.).  Inaglio's  bouillon 
capsules  are  also  very  convenient.  If  it  is  desired  to  make  the 
bouillon  more  nutritious,  one  teaspoonful  of  meat  peptone  may  be 
added. —  {Hepp.) 


790  RECIPES 

Jelly  for  Dyspeptics. — Remove  the  skin  and  meat  from  one  calf's 
foot ;  wash  the  bones  and  place  in  cold  water  on  the  stove ;  when  it 
begins  to  foam,  skim  otf  the  refuse  which  gathers  on  top.  After  rins- 
ing oft'  the  scum  with  cold  water,  put  the  bones  into  a  pot  with  one- 
quarter  kilo  of  beef  or  half  an  old  hen,  one-quarter  liter  of  water, 
and  5  gm.  of  salt,  and  boil  slowl}'  for  from  four  to  five  hours.  Pour 
the  jelly  thus  formed  through  a  fine  sieve,  and  place  overnight  in  a 
cellar.  Next  morning  remove  the  fat,  and  clarify  the  cold  jelly  by 
adding  one  egg  with  its  shell  mashed,  beating  and  stirring  steadily. 
Then,  with  the  addition  of  a  little  cornstarch,  subject  the  whole  to  a 
temperature  not  over  60°  R.,  or  the  white  of  the  egg  will  curdle. 
Constantly  beat  and  stir.  If  the  jelly  begins  to  get  grainy,  cover  and 
let  it  cool  until  the  white  of  the  egg  becomes  flaky  and  separates. 
Then  strain  again  several  times  until  it  becomes  perfectly  clear;  add 
5  gm.  of  extract  of  meat,  pour  the  jelly  into  a  mold,  and  let  it  cool 
again.  The  gravy  from  a  roast  may  be  utilized  and  is  very  palatable. 
It  must  be  stirred  in  while  the  mass  is  still  warm  and  liquid.  This 
jelly  is  usually  relished  with  cold  fowl,  but  spoils  easily  in  summer; 
it  must  therefore  be  kept  on  ice. —  {Weil) 

Dishes  Made  with  Gelatin. — Gelatin  should  be  soaked  in  cold 
water  for  about  half  an  hour  to  soften  it.  It  may  then  be  easily 
dissolved  by  adding  boiling  water.  If  it  is  desired  to  soften  gelatin 
quickly,  it  should  be  placed  in  cold  water  and  gradually  heated  over 
boiling  water  until  it  dissolves.  If  a  jelly  is  to  be  strained,  a  wet 
cloth  should  be  used  for  the  purpose.  Jelly  molds  should  be  wet  with 
cold  water  before  being  filled.  When  granulated  gelatin  is  used, 
much  smaller  amounts  are  required  than  when  the  ordinary  form  is 
used. 

Wine  Jelly. — Soak  a  teaspoonful  of  granulated  gelatin  in  two 
tablespoonfuls  of  cold  water  and  half  a  cupful  of  hot  water.  Add 
two  tablespoonfuls  of  sugar  and  half  a  teaspoonful  of  lemon  juice, 
and  when  cooling  add  two  tablespoonfuls  of  wine. —  (Drexel  Insti- 
tute.) 

Lemon  Jelly  is  made  in  the  same  manner  as  the  wine  jelly  just 
described,  using  a  tablespoonful  of  lemon  juice  in  place  of  the  quan- 
tity directed. 

Orange  Jelly  is  made  in  a  similar  manner,  using  two  teaspoonfuls 
of  lemon  juice,  four  tablespoonfuls  of  orange  juice,  and  three  table- 
spoonfuls of  sugar,  but  a  little  less  of  the  boiling  water. 

Coffee  Jelly  is  also  made  similarly,  adding  an  ounce  or  two  of  coffee. 

Nutritious  Coffee. — Dissolve  a  little  isin-glass  or  gelatin  in  water, 
put  half  an  ounce  of  freshly  ground  coffee  into  a  sauce  pan  with  one 
pint  of  new  milk,  which  should  be  nearly  boiling  before  the  coffee  is 
added ;  boil  together  for  three  minutes ;  clear  it  by  pouring  some  of  it 
into  a  cup  and  dashing  it  back  again ;  add  the  gelatin,  and  leave  it  to 
settle  in  a  warm  place  for  a  few  minutes.     Beat  up  an  egg  in  a  break- 


RECIPEH  FOR  FOODS  FOR  DIABETICS  791 

fast  cup,  and  pour  the  cofl'ee  upuu  it ;  if  preferred  drink  without  the 
eg<?. —  {Thomas.) 

Milk  Jelly. — Take  two  quarts  of  milk  and  add  half  a  pound  of 
sugar.  Boil  for  five  or  ten  minutes.  Cool,  and  add  an  ounce  of 
gelatin  dissolved  in  a  cupful  of  cold  water.  Flavor  with  the  juice  of 
two  or  three  lemons  and  three  glasses  of  good'  Bordeaux  wine. — 
{Schlesinger.) 

Irish=moss  Blanc=mange. — Wash  a  tablespoonful  of  Irish  moss  in 
several  changes  of  water  and  pick  it  over  carefully.  Place  it  in  a 
double  boiler  together  with  half  a  cupful  of  milk.  Cook  until  it 
thickens  when  dropped  on  a  cold  plate.  Add  salt,  strain,  and  flavor. 
Pour  into  a  custard  cup  that  has  first  been  rinsed  in  cold  water.— 
{Drexel  Inst  it  id  e.) 

Meat  Jellies  with  Gelatin. — Use  any  kind  of  meat  broth  desired, 
but  always  one  with  appetizing  flavor.  Add  a  teaspoonful  of  gran- 
ulated gelatin  to  enough  broth  to  cover  it,  and  allow  the  gelatin  to 
soak  for  a  few  minutes.  Then  add  the  remainder  of  a  cupful  of  the 
broth  very  hot  and  stir  until  the  gelatin  is  dissolved.  Strain,  and 
pour  into  molds  to  cool. 

Meat  Jellies  with  Tapioca. — ]\Iix  a  cupful  of  broth  as  above  with 
four  level  tablespoonfuls  of  powdered  tapioca.  Heat  until  quite 
clear,  stirring  constantly.  Add  salt  and  season  as  desired.  Pour  into 
molds  and  cool. 

Meat  Jellies  with  Irish  Moss. — Wash  two  tablespoonfuls  of  Irish 
moss  thoroughly.  Add  this  to  a  cupful  of  hot  broth  and  allow  it  to 
stand  for  half  an  hour ;  then  heat  slowly,  stirring  constantly,  and  boil 
for  ten  minutes,  preferably  in  a  double  boiler.  Strain,  and  pour  into 
molds  and  cool. 

Albuminized  Jelly. — Any  of  the  above  meat  jellies  may  be  ren- 
dered more  nutritious  by  the  addition  of  the  white  of  an  egg.  The 
egg  should  be  well  beaten  and  stirred  into  the  jelly  just  after  it  has 
been  taken  oflt'  the  fire. 

RECIPES  FOR  FOODS  FOR  DIABETICS 

Gluten  Pudding. — A  batter  of  egg,  cream,  and  gluten  flour  is  pre- 
pared.    This  is  flavored  with  lemon  or  other  essences  and  baked. 

Gluten  Pancakes. — Add  gluten  flour  to  one  or  two  eggs  and  beat 
into  a  batter.  The  pancakes  may  be  sweetened  with  a  little  saccharin 
or  eaten  with  glycerin. —  (  Williamson.) 

Jeffries'  Gluten  Biscuit. — Mix  thoroughly  gluten  flour,  one  cup- 
ful ;  best  bran,  previously  scalded,  one  cupful ;  baking-powder,  one 
teaspoonful :  salt  to  taste ;  two  eggs ;  milk  or  water,  one  cupful. 

Diabetic  Muffins. — The  Equivalent  of  an  egg.  These  are  useful 
because  they  have  about  the  same  amount  of  protein  and  fat  as  an 
egg  and  can  be  allowed  in  place  of  an  egg  in  the  diet. 


792  RECIPES 

Protein.  Fat. 

Hepco  flour,  140  grains  60  1 

Eggs    (2)     12  12 

Cream,  40  per  cent.,  UO  com 2  24 

Butter,  45  grams 37 

74  74     • 

Make  twelve  cakes.  Each  cake  contains  6  grams  protein,  6  grams  fat,  and 
approximately  75  calories.      (Joslin.) 

Recipe  for  Lyster  muffins  so  arranged  that  each  is  equivalent  to  one  egg: 

Protein.  Fat. 

Lvster  flour,  1  box,  105  grams   88  4 

Eggs    (2)     12  12 

Cream,  40  per  cent.,  90  c.cm 3  36 

Butter,  60  grams    50 

103  102 

Make  seventeen  muffins.  Each  muffin  contains  6  grams  protein  and  6  grams 
fat.      ( Joslin.  j 

Lyster  Griddle  Cakes. — Use  same  proportions  as  for  muffing,  ex- 
cept to  thiu  batter  with  a  little  milk,  and  fry  with  butter. 

Lyster  Waffles, — ]\Iake  same  as  griddle  cakes  and  use  waffle  iron. 

Potato  Flour  Cakes. — 1  egg,  2  tablespoonfuls  melted  butter,  1 
tablespoonful  cream,  3  tablespoonfuls  potato  flour,  thin  batter  with 
milk  and  fry  in  butter  like  Lyster  griddle  cakes. 

Thin  Cakes. — 2  cups  corn  or  oatmeal,  2  cups  boiling  water,  1 
tablespoonful  butter,  salt.  Mix  quickly,  stirring  hard.  Spread  thin 
while  hot  on  buttered  tin  sheets  and  bake.  Cut  in  squares  before  it 
cools. 

Diabetic  Bread. — Take  one  quart  of  set  milk  or  milk  and  water, 
one  heaping  teaspoonful  of  good  butter,  one-tifth  of  a  cake  of  com- 
pressed yeast  beaten  up  with  a  little  water,  and  two  well-beaten  eggs. 
Stir  in  gluten  flour  until  a  soft  dough  is  formed ;  knead  as  in  making 
ordinary  bread;  place  in  pans  to  raise,  and  when  light  bake  in  a 
hot  oven. —  {James  Stewart.) 

Camplin's  Bran  Cakes. — Take  a  sufficient  quantity — say  a  quart — 
of  wheat  bran,  boil  it  in  two  successive  waters  for  a  quarter  of  an 
hour,  each  time  straining  it  through  a  sieve;  then  wash  it  well  with 
cold  water  (on  the  sieve)  until  the  water  runs  off  perfectly  clear; 
squeeze  the  bran  through  a  cloth  as  dry  as  possible,  and  then  spread 
it  thinly  on  a  dish ;  place  it  in  a  slow  oven ;  if  put  in  at  night,  let  it 
remain  until  the  morning,  when,  if  perfectly  dry  and  crisp,  it  will 
be  ready  for  grinding.  The  bran  thus  prepared  must  be  ground  in 
a  mill,  and  sifted  through  a  wire  sieve  that  has  so  fine  a  mesh  that 
a  brush  must  be  used  to  pass  it  through;  that  which  remains  in  the 
sieve  must  be  reground  until  it  becomes  quite  soft  and  fine.  Take 
of  this  bran  powder  three  ounces  (some  patients  use  four  ounces)  ; 
the  other  ingredients  are  as  follows:  three  new-laid  eggs;  one  and 
one-half  or,  if  desired,  two  ounces  of  butter;  about  half  a  pint  of 


RECIPES  FOR  FOODS  FOR  DIABETICS  793 

milk.  Mix  the  eggs  with  a  little  of  the  milk,  and  warm  the  butter 
with  the  remainder ;  then  stir  the  whole  well  together,  adding  a  little 
nutmeg  or  ginger  or  any  other  agreeable  spice.  Bake  in  small  tins 
(patty  pans),  which  must  be  well  buttered,  in  a  somewhat  quick 
oven  for  about  half  an  hour.  When  baked,  the  cakes  should  be  a 
little  thicker  than  a  captain's  biscuit;  they  may  be  eaten  with  meat 
or  cheese  for  breakfast,  dinner,  or  supper.  At  tea  they  require  a 
somewhat  liberal  allowance  of  butter,  or  they  may  be  eaten  with  curd 
or  with  any  soft  cheese.  It  is  important  that  the  flour  be  prepared 
as  directed  above.  If  the  cakes  do  not  keep  well  or  if  they  have  not 
been  well  prepared,  place  them  before  the  Are  for  ten  minutes  every 
day. 

Almond  Pudding. — Take  two  eggs,  one-quarter  of  a  pound  of 
almond  flour,  one-quarter  of  a  pound  of  butter,  and  three  tabloids  of 
saccharin  dissolved  in  a  tablespoonful  of  brandy.  Warm  the  butter, 
beat  in  the  almond  flour  and  the  yolks  of  the  eggs,  and  add  the  dis- 
solved saccharin.  Whip  the  whites  into  a  stifi:'  froth,  and  beat  all 
together.  Put  into  dariole  molds  and  bake  in  a  quick  oven;  serve 
with  a  little  hot  sauce  made  with  dry  sherry  and  saccharin. —  {Mrs. 
Hart.) 

Almond  Biscuit. — To  each  ounce  of  almond  flour  add  the  whites  of 
two  eggs  and  salt  to  taste.  Whip  the  whites  to  a  stiff  froth,  add  the 
almond  flour,  and  beat  well  together.  Put  in  buttered  patty  pans  and 
bake  in  a  moderately  quick  oven  for  from  fifteen  to  twenty  minutes. 
The  whole  must  be  done  quickly,  and  baked  as  soon  as  the  ingredients 
are  mixed.  This  biscuit  is  a  useful  substitute  for  bread. —  {Mrs. 
Hart.) 

Almond  Cakes  No.  i. — Take  one  pound  of  ground  almonds,  four 
eggs,  two  tablespoonfuls  of  milk,  a  pinch  of  salt.  Beat  up  the  eggs 
and  stir  in  the  almond  flour;  place  in  twelve  flat  tins  and  bake  in  a 
moderate  oven  for  about  fifteen  minutes. —  {Saundby.) 

Almond  Cakes  No.  2. — Break  up  about  one-quarter  of  a  pound  of 
sweet  almonds  in  a  stone  mortar  (or  almond  flour  may  be  used), 
put  the  flour  into  a  linen  bag,  which  should  then  be  immersed  for 
one-quarter  of  an  hour  in  boiling  water,  acidulated  with  a  little  vin- 
egar to  remove  the  small  amount  of  sugar  from  the  almonds.  Mix 
well  with  three  ounces  of  butter  and  two  eggs.  Then  the  yolks  of 
three  eggs  and  a  little  salt  are  added,  and  the  whole  stirred  briskly 
for  some  time.  Beat  the  whites  of  three  eggs  to  a  fine  froth  and 
add  to  the  mixture.  The  paste  is  then  made  into  biscuits,  smeared 
with  butter,  and  baked  with  a  gentle  fire. —  {Seegen.) 

Aleuronat  Bread. — Take  about  six  or  seven  ounces  of  ordinary 
wheat  flour  and  the  same  quantity  of  aleuronat  powder;  five  ounces 
of  the  best  butter ;  one  teaspoonful  of  salt ;  three-quarters  of  an  ounce 
of  baking  powder.  The  flour  and  the  aleuronat  are  mixed  in  a  warm 
dish,  and  the  melted  butter  and  milk   (made  lukewarm)   are  added 


794  RECIPES 

gradually,  followed  by  the  salt,  and  finally  by  the  baking-powder 
(one  part  of  sodium  carbonate  and  two  parts  of  cream  of  tartar). 
The  dough  is  well  mixed,  then  molded  into  two  loaves,  and  baked  at 
a  good  heat. —  i  Ebstein.) 

Aleuronat  and  Almond  Cakes. — Three  ounces  of  aleuronat;  three 
ounces  of  almond  flour;  beat  up  one  egg,  and  add  about  two  tea- 
spoonfuls  of  cream  and  a  little  water.  Moisten  the  aleuronat  with  a 
little  water  containing  saccharin  and  let  it  stand  for  a  few  minutes; 
then  add  the  almond  flour,  the  egg,  the  cream,  and  the  water  just  as 
required  to  make  a  light  paste.  Spread  on  a  tin.  Cut  into  squares, 
and  bake  in  a  moderate  oven  for  twenty  minutes. —  (Williamson.) 

Aleuronat  Pancakes. — Take  one  egg  and  beat  it  up  in  a  little 
water  and  cream ;  take  two  teaspoonfuls  of  aleuronat  powder  and 
half  a  teaspoonful  of  baking-powder  and  a  little  salt.  IMix  well,  and 
then  add  gradually  to  the  egg  and  cream  and  beat  into  a  batter; 
allow  it  to  stand  for  five  minutes.  If  it  is  too  thick,  add  a  little  more 
cream  and  water.  Fry  in  an  ordinary  frying-pan  greased  with  a 
little  lard.  At  the  end  of  about  eight  minutes,  when  tlie  under  sur- 
face is  browned,  turn  it  over  and  continue  to  bake  for  five  minutes 
longer. —  ( Williamson. ) 

Aleuronat  and  Suet  Pudding. — This  is  a  palatable  and  cheap 
dish.  To  make  it  take  two  ounces  of  aleuronat  flour  and  two  ounces 
of  suet,  one  egg,  a  pinch  of  salt,  and  half  a  teaspoonful  of  baking- 
powder.  Sprinkle  a  little  aleuronat  flour  on  a  chopping-board  and 
chop  the  suet  on  this  part  of  the  board.  Then  mix  the  remaining 
aleuronat  with  the  suet  in  a  saucepan.  Add  the  salt  and  the  baking 
powder.  Beat  up  the  egg  in  about  three  tablespoonfuls  of  water  to 
which  a  little  saccharin  has  been  added.  Add  the  e^^  gradually  to 
this  mixture,  rubbing  the  whole  mass  well  into  a  paste.  It  may  be 
necessary  to  add  a  little  more  water.  Drop  into  a  tin  pudding  mold 
smeared  with  butter  or  lard,  float  it  in  a  pan  of  water,  and  boil  for 
two  hours,  taking  care  that  the  boiling  water  does  not  get  into  the 
mold :  or,  better  still,  the  pudding  may  be  baked  in  the  oven.  Its 
taste  is  improved  by  the  addition  of  half  an  ounce  of  almonds.  A 
small  quantity  of  red  wine  may  serve  as  a  sauce. —  {Williamson.) 

Cocoanut  Pancakes. — Beat  up  one  egg  in  two  tablespoonfuls  of 
milk,  or,  better,  in  a  little  cream  and  water,  and  add  a  pinch  of  salt. 
Then  add  two  tablespoonfuls  of  cocoanut  powder  (freed  from  sugar). 
Allow  this  to  stand  for  from  five  to  ten  minutes.  Add  a  little  more 
cream  and  water.  ]\Iix  well  until  it  is  a  little  thicker  than  ordinary 
pancake  batter.  Put  a  little  lard  in  the  frying-pan  and  heat  until 
the  lard  is  just  melted;  then  drop  in  half  of  the  mixture.  Allow  this 
to  remain  over  a  moderate  fire  for  a  few  minutes — about  five — until 
the  under  surface  is  brown ;  then  turn  the  cake  over  and  heat  for 
another  five  minutes.  The  other  half  of  the  mixture  may  be  used  for 
the  second  pancake. —  {Williamson.) 


RECIPES  FOli  FOODS  FOR  DIABETICS  795 

Cocoanut  Cakes. — Mix  three  tablespoonfuls  of  cocoanut  powder 
into  a  paste  with  a  little  yeast  and  water.  The  mixture  should  be 
allowed  to  remain  by  the  tire  or  in  a  warm  place  for  about  twenty 
minutes,  or  until  fermentation  occurs  and  it  becomes  '"puffy." 
Then  add  a  small  quantity  of  a  watery  solution  of  saccharin.  Beat 
up  one  egg,  and  add  this  with  two  teaspoonfuls  of  cream  and  a  little 
water  to  the  cocoanut  paste.  The  whole  should  be  well  mixed,  dropped 
into  small  tins,  and  baked  in  an  oven  for  about  thirty  minutes. — 
( Williamson.) 

Cocoanut  and  Almond  Cakes. — To  make  these,  the  following  in- 
gredients are  required:  Three-quarters  of  a  pound  of  the  finest 
cocoanut  powder,  one-quarter  of  a  pound  of  ground  almonds,  six  eggs, 
and  half  a  cupful  of  milk.  Beat  up  the  eggs  and  stir  in  the  cocoanut 
and  almond  flour.  Divide  into  sixteen  flat  tins,  and  bake  for  twenty- 
five  minutes  in  a  moderate  oven. —  {Saiindhy.) 

Cocoanut  Pudding. — Take  three  tablespoonfuls  of  cocoanut  powder, 
mix  with  a  little  water  and  yeast,  and  keep  for  twenty  minutes  in 
a  warm  place,  so  as  to  allow  the  small  quantity  of  sugar  present 
to  decompose;  add  four  tablespoonfuls  of  cream,  one  egg,  a  lit- 
tle salt,  and  half  a  pint  of  water  sweetened  with  saccharin.  Mix 
into  a  paste.  Place  in  a  dish  greased  with  butter.  Cook  like  rice 
pudding,  in  a  slow  oven  for  thirty  minutes. —  (Williamson.) 

Light  Custard. — Beat  up  well  one  egg;  make  a  mixture  of  cream 
and  water  and  boil ;  gradually  add  the  boiled  cream  and  water,  while 
hot,  to  the  egg,  stirring  with  a  spoon.  Then  place  the  mixture  in  a 
pan  over  the  fire,  and  stir  constantly  until  it  becomes  thick;  then 
pour  into  a  glass.  It  is  important  that  the  mixture  should  not  be 
heated  too  much — i.  e.,  that  it  be  not  boiled — as  the  albumin  would 
be  coagulated.  Flavor  with  cinnamon  and  sweeten  with  saxin  or 
saccharin  if  desired. 

Cheese  Cakes. — Take  one  pint  of  milk,  half  a  tablespoonful  of 
rennet,  one  ounce  of  butter,  two  eggs,  one  tablespoonful  of  brandy, 
one-quarter  of  an  ounce  of  almonds,  and  a  little  saccharin.  Curdle 
the  milk,  and  let  it  stand  in  a  warm  place  until  thoroughly  set ;  tie 
a  piece  of  muslin  over  a  bowl  and  pour  the  milk  over  the  nuislin;  let 
it  stand  until  all  the  whey  has  been  strained  otf.  Beat  the  curd 
smooth,  and  add  the  butter  and  egg,  well  beaten,  w'ith  the  brandy, 
almonds,  and  saccharin.  When  well  mixed  pour  into  patty  pans  and 
bake  for  fifteen  or  twenty  minutes. —  {Mrs.  Hart.) 

Stewed  Lettuce. — A  well-grown  head  of  lettuce  should  be  selected. 
Boil  this  in  plenty  of  water,  taking  care  not  to  let  it  fall  to  pieces. 
When  nearly  done  take  it  out  of  the  water,  drain,  and  place  in  a 
stewpan  with  a  little  rich  broA\ai  gra\y  and  allow  it  to  simmer  for 
twenty  minutes. 

Inulin  Biscuit. — Put  50  gm.  (li/o  oz.)  of  inulin  in  a  large  por 
celain  basin,  place  this  over  a  hot-water  bath,  and  with  30  c.c.  (1  oz.) 


796  RECIPES 

of  milk  and  as  much  hot  water  as  may  be  necessary,  rub  up  into  a 
smooth  dough,  into  which  the  yolks  of  four  eggs  and  a  little  salt  have 
been  mixed.  To  this  add  the  whites  of  the  four  eggs,  having  first 
beaten  them  to  a  foam,  and  working  them  in  carefully.  Bake  in  tin 
molds  smeared  with  butter.  The  taste  of  the  biscuit  may  be  improved 
by  adding  vanilla  or  other  flavoring  extract.  Inulin  is  too  expensive 
to  be  used  by  the  average  patient. 

Peanut  Flour. — This  contains  about  25  per  cent,  of  carbohj'drates. 
The  peanut  kernels  should  be  boiled  in  water  for  half  an  hour  to 
extract  a  portion  of  the  oil  which  they  contain.  They  should  then 
be  dried,  and  rolled  into  fine  particles  with  a  rolling-pin.  Place  the 
kernels  in  boiling  water  acidulated  with  tartaric  acid  or  vinegar,  in 
order  (1)  to  extract  saccharin  elements;  (2)  overcome  the  taste  and 
odor  of  the  peanut;  (3)  to  prevent  emulsification  of  the  remaining 
oil.  When  they  have  been  thoroughly  boiled  in  acidulated  water,  the 
ground  kernels  should  be  subjected  to  dry  heat  and  then  rolled  into 
a  fine  flour.  This  flour  may  be  made  into  a  form  of  porridge  with 
milk ;  bread  and  biscuits  may  also  be  baked  from  it ;  and  it  may  be 
made  into  the  form  of  a  pancake. —  {Stern.) 

Home=made  Substitute  for  Bread.- — Beat  up  thoroughly  six  eggs; 
add  a  teaspoonful  of  baking-powder  or  its  chemical  equivalent,  and 
one-quarter  of  a  teaspoonful  of  salt,  and  beat  again.  Pour  this  mix- 
ture into  hot  waffle-irons  smeared  with  butter,  and  bake  in  a  very  hot 
oven.  By  way  of  variety  almonds  (powdered)  may  be  added.  These 
biscuits  may  be  eaten  hot  with  butter  and  cheese. 

Cracked  Cocoa. — The  so-called  cocoa  nibs  makes  a  most  useful 
drink  for  diabetic  patients,  according  to  Joslin.  He  gives  the  analysis 
by  Street,  as  follows: 

Moisture     2.83 

Protein     14.69 

Fat    51.42 

Fiber     4.32 

Ash    3.88 

Starch     7.48 

Reducing  sugar,  as  dextrose,  direct  none 

Reducing  sugar,  as  dextrose,  after  inversion ....  0.fl4 

The  cocoa  is  prepared  by  adding  a  cupful  of  the  cracked  cocoa 
to  a  cup  of  water  and  boiling  all  day,  adding  water  from  time  to 
time. 

Milk  for  Diabetics. — One  part  cream,  three  parts  water,  and  add 
the  white  of  one  egg,  previously  beaten  and  strained,  to  each  30  c.c. 
(1  ounce)  of  the  mixture.  Sweeten  with  saccharin  if  desired,  and 
stir  well  before  serving. 

Sugar=free  Milk  for  Diabetic  Feeding. — Take  1  liter  of  skim  milk, 
heat  to  a  temperature  of  30°  C,  and  add  10  c.c.  of  glacial  acetic  acid, 
diluted  with  100  c.c.  of  water.  Mix,  and  allow  the  mixture  to  stand 
for  about  fifteen  minutes.     Collect  the  separated  casein,  and  let  it 


RECIPES  FOR  FOODS  FOR  DIABETICS  797 

drain  on  very  fine  muslin,  using-  no  pressure.  Remove  the  casein  to 
a  mortar,  rub  into  a  smooth  paste,  add  y^  liter  of  distilled  water,  and 
strain  as  before.  Repeat  this  washing  of  the  casein  twice.  Transfer 
to  a  mortar,  rub  until  quite  smooth,  and  add  2i/2  gm.  of  potassium 
hydrate  dissolved  in  100  c.c.  of  water  (or  as  much  of  the  potassium 
hydrate  as  is  necessary  to  make  the  product  just  alkaline  to  phe- 
nolphtlialein).  Add  100  gm.  of  ordinary  Devonshire  clotted  cream, 
5  gm.  of  gelatin,  previously  dissolved,  0.06  gm.  (1  gr.)  of  saccharin, 
and  water,  at  about  38''  C,  up  to  1  liter.  Lastly,  strain  through  fine 
muslin . —  ( //  u  i  chinson . ) 

Soups  for  Diabetics. — Consomme. — Three  pounds  of  beef  from  the 
round,  one  small  knuckle  of  veal,  five  quarts  of  cold  water,  simmer 
four  hours,  then  add :  one  pound  each  of  carrots,  turnips,  and  onions 
cut  into  dice,  one  teaspoonful  of  salt,  one-half  teaspoonful  of  sweet 
marjoram,  one-half  teaspoonful  of  thyme,  one  teaspoonful  of  pepper- 
corns, one  bay  leaf,  one  sprig  of  parsley.  Simmer  one  hour,  strain 
and  cool ;  when  cold,  skim  off  the  fat. 

Consomme  with  Brussels  Sprouts. — To  three  pints  of  hot  consomme 
add  two  cupfuls  of  Brussels  sprouts  which  have  been  soaked  in  cold 
water  twenty  minutes,  and  boiled  in  boiling  salted  water  fifteen 
minutes. 

Consomme  with  Claret. — To  one  pint  of  consomme  add  one  pint  of 
claret,  one  pint  of  hot  water,  pour  one  cupful  of  consomme  over  the 
yolks  of  three  eggs ;  cook  until  the  spoon  is  coated ;  add  the  beaten  eg^ 
whites.     Mix  and  serve  either  hot  or  cold. 

Consomme  with  Cucumbers. — To  three  pints  of  consomme  add  two 
sliced  cucumbers  which  have  been  cooked  one-half  hour  in  one  cupful 
of  water.  For  the  cucumbers  may  be  substituted :  red  or  white  cab- 
bage, cauliflower,  asparagus,  cooked  meats  chopped,  or  Parmesan 
cheese. 

Tomato  Soup. — Stew  tomatoes  with  butter,  strain,  and  add  an  equal 
quantity  of  consomme. 

Jacobin  Cubes. — Beat  three  eggs  in  a  bowl,  add  some  nutmeg  and 
three  teaspoonf uls  of  water ;  place  the  bowl  in  boiling  water  until  the 
mixture  thickens ;  cut  in  cubes  and  serve  in  broth. 

Spinach  Pudding". — Mix  with  one  quart  of  boiled  spinach  four 
yolks,  add  one-half  of  an  onion,  one-half  cupful  of  cream,  whites 
whipped  stifif,  and  one-half  cupful  of  ham  cut  in  cubes.  Place  the 
mixture  in  a  well-buttered  dish  and  steam  in  a  "bain  Marie." 

Russian  Dressing.- — 1  can  of  tomatoes  boiled  down  until  very  dry, 
then  put  through  a  fine  sieve  and  add  saccharin  to  sweeten,  as  desired. 
If  one  desires  there  can  be  added  chopped  olives,  capers,  chopped  fresh 
peppers,  then  mix  equal  proportions  of  mayonnaise  dressing. 

Hollandaise  Sauce. — -Juice  of  one  lemon;  add  1  cup  of  water  and 
put  in  double  boiler  and  allow  to  come  to  a  boil,  then  add  1  egg,  and 
one  tablespoonful  of  butter,  these  last  two  beaten  together  as  for  cake. 


798  RECIPES 

Stir  in  egg  and  butter,  stirring  constantly  to  prevent  curdling. 
Tomato  Jelly  Salad. — To  one  can  of  stewed  and  strained  tomatoes 
add  one  teaspoonful  of  salt  and  two-thirds  of  a  box  of  gelatin  soaked 
and  dissolved.  Pour  into  small  cups  and  chill.  Serve  on  lettuce 
leaves  with  mayonnaise  dressing. 

Lemon  Jelly   (Diabetic) 

Food.  Amount.  ^/ram.'''  ™s       ^ydrafe.    Calories. 

^         '  ■        grams. 

Lemon  juice     .30  c.cm.  .  .  .  .              3             12 

Water    .iO  c.cm. 

Gelatin     4  grams.  4  .  .            .  .              16 

Saccharin    (to  sweeten) 

Cream    30  c.cm.  1  12             1           116 

5  12  4  144 

Soften  gelatin  in  part  of  the  cold  water.  Heat  the  remaining  water  and  lemon 
juice  and  pour  over  the  gelatin.  Stir  until  dissolved.  Add  saccharin,  strain 
into  cups.     Serve  with  cream.      (Joslin.) 

Ice  Cream    (Diabetic) 

Food.  Amount.  ^.ram<f'       sr^-fm*        hydrate,    Calories. 

f,rams.        grams.        grams. 

Cream   (40  per  cent.)    00  c.cm.  3  36  3  .348 

Water      10  c.cm. 

Egg   ( 1 )    50  grams  6  6  .  .  78 

Saccharin    (to  sweeten) 

Flavoring    (to  taste) 

9  42  3  426 

Make  a  soft  custard  of  the  egg,  50  c.cm.  of  the  cream,  and  the  water.  Whip 
the  remkining  40  c.cm.  of  the  cream  and  fold  into  custard.  The  saccharin  may 
be  added  to  the  egg.     The  flavoring  should  lie  added  last.      (Joslin.) 

Bavarian  Cream   (Diabetic) 

Food.  Amount.  ^Jlfml^'       Jam.        hydrate,    Calories. 

grams.        grams.        grams. 

Cream    ( 40  per  cent. )    90  c.cm.                 3             36             3           348 

Water      10  c.cm. 

Egg    ( 1 )     50  grams               6               6            . .              78 

Gelatin 2  grams               2              .  .            . .                8 

Saccharin    (to  sweeten) 

Flavoring   (to  taste) 

11  42  3  434 

Soften  the  gelatin  in  cold  water,  then  add  to  the  cream,  which  has  been  heated. 
Stir  until  dissolved,  pour  on  the  beaten  egg,  cook  like  soft  custard,  turn  into 
mold  and  chill.      (Joslin.) 

Soy  Bean  Cookery.^ — In  diabetes  the  beans  may  be  added  to  the 
diet  simply  to  give  variety,  and  they  may  also  be  used  to  great  ad- 
vantage in  connection  with  an  otherwise  carbohydrate-free  diet,  par- 
ticularly in  those  cases  in  which  the  sugar  percentage  is  high,  and  it 
is  with  these  cases  we  have  had  particular  success. 

The  simplest  way  to  use  the  beans  is  to  cook  them  like  the  ordinary 
navy  bean,  preparing  either  bean  soup,  boiled  beans,  or  baked  beans, 

iRuhrah,  Medical  Record,  Sept.  23,  1911. 


Fat. 

Carbohydrates. 

0.15 

0.08 

0.60 

0.30 

h'EClPEl-i  FOlf  FOODti  FON  1)1  MiETKd  799 

the  flavor  usually  being  rather  improved  by  the  addition  of  a  piece  of 
fat  salt  meat.  It  is  also  a  good  plan  to  soak  the  beans  for  eight  or 
ten  hours,  stir  them  up,  and  remove  the  rather  tirm  envelope  which 
encloses  them,  most  of  which  will  be  found  to  come  to  the  surface, 
from  which  they  may  be  easily  skimmed  off.  The  beans  may  be  boiled 
and  reduced  to  a  smooth  gruel  and  used  in  this  way  as  a  gruel,  al- 
though this  is  rather  a  tronble.some  process;  or  the  beans  may  be 
thoroughly  boiled  and  mashed  and  may  be  flavored  with  some  other 
vegetable,  particularly  stewed  tomatoes.  The  soy  bean  flour  may  be 
utilized  in  many  ways. 

Gruels. — A  quart  of  gruel  is  made  by  boiling  from  1  level  table- 
spoonful  to  6  ounces  of  the  soy  flour  (made  by  the  Cereo  Company, 
Tappan,  X.  Y.)  in  1  quart  of  water  for  fifteen  minutes,  adding  water 
to  make  up  for  the  loss  of  evaporation.  Salt  should  be  added  to 
taste. 

Protein. 

1   level  tablespoonful  to  quart    0.35 

1  ounce  4   (tablespoonfuls)    lo  (juait     ...      1.40 

These  gruels  do  not  thicken  during  cooking,  as  they  contain  no  starch, 
and  readily  settle  on  standing.  This  may  be  overcome  by  adding  1 
to  2  heaping  teaspoonsful  of  barley,  oat,  or  wheat  gruel  flour  before 
cooking,  W'hieh  will  add  0.6  to  1.2  per  cent,  starch  to  the  gruels,  and 
also  slightly  increase  the  percentage  of  protein. 

Broths. — Add  1  to  8  ounces  of  the  flour  to  1  quart  of  beef,  mutton, 
veal,  or  chicken  broth  and  boil  for  fifteen  minutes,  adding  water  to 
make  up  for  loss  of  evaporation ;  or,  boil  the  same  quantity  of  the 
soy  flour  for  one  hour  with  1  quart  of  water,  to  which  has  been 
added  a  piece  of  ham,  bacon,  or  salt  pork  to  give  flavor.  Each  ounce 
of  the  flour  will  add  to  the  broth  about  13  grams  of  protein  and  120 
calories,  or  in  percentage  add  1.4  per  cent,  protein,  0.60  per  cent,  fat, 
and  0.30  per  cent,  carbohydrates.  A  broth  made  with  6  ounces  of 
the  soy  flour  to  the  quart  would  be  half  as  rich  in  protein  and  fat 
as  steak. 

MujfiJis. — To  make  muffins  from  the  soy  flour,  take  li/4  teacupfuls 
of  the  soy  flour,  y^  teacupful  of  wheat  flour,  lA  teaspoonful  of  salt, 
2  eggs,  1  teacupful  of  sweet  milk,  2  rounded  teaspoonfuls  of  baking 
powder,  and  lyo  tablespoonfuls  of  melted  but  not  hot  butter.  Beat 
well  together,  adding  the  melted  butter  last,  and  bake  in  gem  pans 
in  a  hot  oven.  This  will  make  about  12  muffins  which  will  contain 
about  150  grams  of  protein,  and  which  will  yield  about  1800  calories, 
of  Avhich  the  carbohydrates  produce  but  280.  Inasmuch  as  the  soy 
flour  contains  no  starch,  the  addition  of  some  w^heat  flour  in  making 
muffins  is  required.  The  mixture  of  wheat  and  soy  flour  in  this 
formula  will  contain  about  36  per  cent,  protein  and  20  per  cent, 
carbohydrates,  against  14  per  cent,  protein  and  60  to  70  per  cent, 
carbohydrates   in   gluten  flour.     The  proportion   of  protein  to   car- 


800  RECIPES 

bohydrates  is  eight  to  ten  times  as  large  in  the  mixed  soy  and  wheat 
flour  as  in  the  gluten  flour. 

In  addition  to  these  methods,  the  following  recipe  for  muffins  has 
been  suggested  by  Dr.  Skinner,  of  New  Haven,  Conn.:  Soy  bean 
flour,  11/2  eupfuls;  salt,  VL'  teaspoonf ul ;  baking  powder,  2  even  tea- 
spoonfuls.  Mix  well  and  add  2  tablespoonfuls  of  cream  which  has 
first  been  thoroughly  stirred  into  a  cup  of  cold  water.  Add  2  eggs 
and  beat  together.  Then  add  2  tablespoonfuls  of  melted  butter  and 
beat  the  whole  mixture  well  together.  Bake  fifteen  minutes  in  a 
heated  gem  pan.     The  above  makes  15  muffins. 

Another  recipe  for  muffins  is  to  beat  up  3  eggs,  add  1  cup  of  milk 
in  which  1  grain  of  saccharin  has  been  dissolved,  and  a  lump  of 
butter  the  size  of  an  egg.  Enough  of  the  bean  flour  should  be  added 
to  make  a  batter  with  1/2  teaspoonful  of  baking  powder.  This  should 
be  baked  in  buttered  muffin  pans. 

Nut-cakes. — These  may  be  made  by  using  the  above  muffin  recipe 
as  a  basis  and  adding  chopped  nuts,  almonds,  or  any  other  kind 
desired ;  and  the  flour  is  improved  by  the  addition  of  a  small  amount 
of  spice. 

Soy  Bean  Cakes. — These  may  be  made  by  taking  1  tablespoonful  of 
cocoa,  1  teaspoonful  of  cinnamon,  1  teaspoonful  of  allspice,  and 
chopped  nuts,  adding  them  to  the  batter  as  prepared  for  the  muffins. 

Breakfast  Food. — As  a-  breakfast  food  it  may  be  utilized  by  taking 
1  cup  of  flour,  enough  milk  or  water  to  moisten  it  into  a  paste,  a 
pinch  of  salt,  and  1  grain  of  saccharin,  which  should  be  dissolved 
before  adding.  Boil  one  and  a  half  hours  in  a  double  boiler  and 
serve  with  rich  cream. 

Pancakes. — These  may  be  made  by  beating  up  2  eggs  with  a  pinch 
of  salt,  adding  enough  meal  to  make  a  batter,  and  14  teaspoonful  of 
baking  powder.  This  should  be  fried  with  butter  and  made  into 
small  cakes. 

Soy  Bean  Cheese. — In  China  and  Japan  the  bean  is  used  chiefly 
in  the  form  of  a  cheese-like  substance,  the  most  common  forms  of 
this  being  natto,  tofu,  miso,  yuba,  and  shoyu.  These  cheeses  are 
eaten  daily  by  almost  all  the  inhabitants  of  the  East,  but  they  are 
said  to  have  a  lack  of  flavor  that  renders  them  more  or  less  unsuited 
for  European  and  American  palates.  In  Seattle,  AVash.,  and  other 
places  in  the  West  we  are  informed  that  tofu  is  made  by  the  Japanese 
and  sold  to  the  Oriental  residents.  We  have  not  had  any  personal 
experience  so  far  with  the  bean  cheeses,  although  they  are  evidently 
very  easy  to  manufacture.  One  maj'  be  made  from  the  gruel  which 
resembles  somewhat  curds  and  whey,  but  which  in  the  only  form  we 
have  tried  is  not  sufficiently  palatable  for  use,  although  very  slight 
flavoring  might  make  it  a  valuable  food  for  American  use. 


RECIPES  FOR  FOODS  FOR  DIABETICS  801 

The  following  suggestions  for  cooking  the  bean  are  made  by  Gott":  ^ 

Grilled  Soy  Beans. — The  beans  may  be  grilled  like  chestnuts,  using 
the  same  method.  If  the  beans  are  old  and  dry  they  should  be  first 
soaked  in  warm  water. 

Soy  Beans  with  Butter. — Let  the  beans  soak  in  warm  water  until 
the  hulls  are  separated  and  float  upon  the  surface,  then  let  them  strain 
for  twenty-four  hours,  when  they  should  be  cooked,  according  to  the 
age  of  the  grains,  from  one  to  four  hours,  and  seasoned  to  taste. 
They  should  then  be  strained  again  and  served  hot  with  butter  on 
lettuce  or  romaine. 

Soy  Beans  an  Gras. — Place  a  chopped  onion  in  a  casserole  of  fat 
and  fry  it  until  the  onion  becomes  brown.  Then  add  the  soy  beans 
cooked  as  above,  and  allow  them  to  cook  a  few  minutes  longer. 

Bread  or  Cakes  of  Soy  Beans. — Triturate  in  a  mortar  250  grams  of 
soy  flour  with  2  fresh  eggs  and  a  large  spoonful  of  milk.  When  this 
is  perfectly  mixed,  add  a  pinch  of  baking  powder,  place  in  well- 
buttered  molds,  and  cook  from  fifteen  to  twenty  minutes.  This  may 
be  flavored  with  vanilla,  orange-flowers,  or  with  pieces  of  citron. 
They  may  be  divided  into  small  cakes  and  then  cooked  in  very  small 
molds. 

1  Gazette  dee  Hopitaux,  March  7,  1911,  p.  399. 
51 


THE  CHEMICAL  COMPOSITION  OF  AMERICAN 
FOOD  MATERIALS 

The  material  in  this  section  has  been  taken  from  the  revised  edi- 
tion of  Bulletin  No.  28  of  the  Experiment  Stations  of  the  Department 
of  Agriculture  of  the  United  States.  This  very  valuable  bulletin 
was  prepared  by  W.  0.  Atwater  and  A.  P.  Bryant,  and  represents 
the  best  compilation  of  analyses  of  American  food  materials  down  to 
1899.  Only  the  averages  have  been  abstracted  from  the  tables;  for 
ordinary  purposes  these  will  be  found  to  be  sufficient ;  for  the  complete 
tables  tiie  reader  should  refer  to  the  original  bulletin. 

The  earliest  quantitative  food  analyses  were  made  in  1795  by  Pear- 
son, in  England,  who  analyzed  potatoes.  In  1805  Einhoff"  analyzed 
potatoes  and  rye.  Later  other  workers  gave  various  accounts  of  their 
work,  but  the  great  impetus  to  the  study  of  food  materials  was  given 
by  Liebig  and  his  followers,  whose  work  was  done  chiefly  in  the  period 
between  1840  and  1865.  About  186-1:  Henneberg  and  his  associates 
elaborated  the  so-called  Weende  method  for  proximate  analysis.  This 
method,  with  slight  alterations,  is  used  to-day  wherever  food  analyses 
are  made.  "The  methods  followed  in  different  countries  agree  so 
closely  that  for  the  last  twenty  years  it  has  been  possible  to  accept 
analyses  by  chemists  in  dift'erent  parts  of  the  world  and  compare 
them  with  one  another  without  hesitation"  (Atwater  and  Bryant). 
Since  the  establishment  of  the  experiment  stations  an  enormous 
amount  of  work  has  been  done.  The  results  given  in  the  tables  show 
the  averages  of  thousands  of  analyses ;  these,  together  with  the  accom- 
panying list,  have  been  taken  directly  from  Atwater  and  Bryant's  pub- 
lication. 

EXPLANATION  OF  TERMS  ^ 

The  terms  used  in  reporting  analyses  of  foods  and  feeding-stuffs 
need  some  explanation.  Some  of  these  terms  have  a  technical  mean- 
ing which  is  well  recognized  and  understood  by  scientists,  although 
the  dictionaries  and  similar  books  of  reference  have  not  yet  included 
these  uses  in  their  definitions.  In  other  cases  the  same  word  has 
been  used  by  scientists  in  dift'erent  ways.  The  more  usual  terms  are 
defined  and  explained  below  in  the  sense  in  which  they  are  employed 
in  the  following  table  and  the  publications  of  the  Experiment  Stations 
of  the  United  States  Department  of  Agriculture. 

1  These  definitions  are  quoted  from  Atwater  and  Bryant. 

802 


COMPOSfTlOS  OF  FOOD  MMFIilM.H  803 

COMPOSITION  OF  FOOD  MATERIALS 

Ordinary  food  materials,  such  as  meat,  Hsli,  eggs,  potatoes,  wheat, 
etc.,  consist  of: 

Refuse. — As  the  bones  of  meat  and  lish,  shells  of  shelliish,  skin  of 
potatoes,  bran  of  wheat,  etc. 

Edible  Portion. — As  the  flesh  of  meat  and  fish,  the  white  and  yolk 
of  eggs,  wheat  flour,  etc.  This  edible  portion  consists  of  water  (usu- 
ally incorporated  in  the  tissue  and  not  visible  as  such),  and  nutritive 
ingredients  or  nutrients. 

The  principal  kinds  of  nutritive  ingredients  are  protein,  fats,  car- 
bohydrates, and  ash  or  mineral  matters. 

The  water  and  refuse  of  various  foods  and  the  salt  of  salted  meat 
and  fish  are  called  non-nutrients.  In  comparing  the  values  of  differ- 
ent food  materials  for  nourishment  they  are  left  out  of  account. 

Protein. — This  term  is  used  to  include  nominally  the  total  nitrog- 
enous substance  of  animal  and  vegetable  food  materials,  exclusive  of 
the  so-called  nitrogenous  fats.  Actually  it  is  employed,  in  common 
usage,  to  designate  the  product  of  the  total  nitrogen  by  an  empirical 
factor,  generally  6.25. 

This  total  nitrogenous  substance  consists  of  a  great  variety  of 
chemical  compounds,  which  are  conveniently  divided  into  two  princi- 
pal classes,  proteids  and  non-proteids. 

The  term  proteid,  as  here  employed,  includes:  (1)  The  simple 
proteids,  e.  g.,  albuminoids,  globulins,  and  their  derivatives,  such  as 
acid  and  alkali  albumins,  coagulated  proteids,  proteoses,  and  pep- 
tones; (2)  the  so-called  combined  or  compound  proteids;  and  (3) 
the  so-called  gelatinoids  (sometimes  called  "glutinoids")  which  are 
characteristic  of  animal  connective  tissue. 

The  term  albuminoids  has  long  been  used  bj'  European  and  Amer- 
ican chemists  and  physiologists  as  a  collective  designation  for  the 
substances  of  the  first  two  groups,  though  many  apply  it  to  all  three 
of  these  groups.  Of  late  a  number  of  investigators  and  writers  have 
employed  it  as  a  special  designation  for  compounds  of  the  third  class.^ 

The  term  non-proteid  is  here  used  synonymously  with  non-albu- 
minoid, and  includes  nitrogenous  animal  and  vegetable  compounds  of 
simpler  constitution  than  the  proteids.  The  most  important  animal 
compounds  of  this  class  are  the  so-called  "nitrogenous  extractives" 
of  muscular  and  connective  tissue,  such  as  creatin,  creatinin,  xanthin, 
hypoxanthin,  and  allied  cleavage  products  of  the  proteids.  To  some 
of  these  the  term  "meat  bases"  has  been  applied.  The  latter,  with 
certain  mineral  salts  (potassium  phosphates,  etc.),  are  the  most  im- 
portant constituents  of  beef -tea  and  many  commercial  "meat  ex- 
tracts. ' ' 

1  United  States  Department  of  Agriculture,  Office  of  Experiment  .Stations, 
Bulletin  65,  p.  118. 


804        CHEMICAL  COMPOSITIOX  OF  AMERICAX  FOOD  MATERIALS 

The  non-proteid  nitrogenous  compounds  in  vegetable  foods  consist 
of.  amids  and  amido  acids,  of  which  asparagin  and  aspartic  acid  are 
familiar  examples. 

The  ideal  method  of  analysis  of  food  materials  would  involve  quan- 
titative determinations  of  the  amounts  of  each  of  the  several  kinds  or 
groups  of  nitrogenous  compounds.  This,  however,  is  seldom  at- 
tempted. The  common  practice  is  to  multiply  the  percentage  of 
nitrogen  by  the  factor  6.25  and  take  the  product  as  representing  the 
total  nitrogenous  substance.  For  many  materials,  animal  and  vegeta- 
ble, this  factor  would  be  nearly  correct  for  the  proteids,  which  con- 
tain, on  the  average,  not  far  from  16  per  cent,  of  nitrogen,  although 
the  nitrogen  content  of  the  individual  proteids  is  quite  varied.  The 
variations  in  the  nitrogen  of  the  non-proteids  are  w4der,  and  they 
contain,  on  the  average,  more  than  16  per  cent,  of  nitrogen.  It  is 
evident,  therefore,  that  the  computation  of  the  total  nitrogenous  sub- 
stance in  this  way  is  by  no  means  correct.  In  the  flesh  of  meats  and 
fish,  which  contain  very  little  of  carbohydrates,  the  nitrogenous  sub- 
.stance  is  frequently  estimated  by  difit'erence — i.e.,  by  subtracting  the 
ether  extract  and  ash  from  the  total  water-free  substance.  While 
this  method  is  not  ahvays  correct,  it  is  oftentimes  more  nearly  so  than 
the  determination  by  use  of  the  usual  factor. 

The  distinction  between  protein  and  proteids  is  thus  very  sharp. 
The  latter  are  definite  chemical  compounds,  while  the  former  is  an 
entirely  arbitrary  term  used  to  designate  a  group  which  is  commonly 
assumed  to  include  all  of  the  nitrogenous  matter  of  the  food  except 
the  nitrogenous  fats. 

In  the  tables  herewith  the  common  usage  is  followed,  by  which  the 
protein  is  given  as  estimated  by  factor — /.  e.,  total  nitrogen  multiplied 
by  6.25.  In  the  analyses  of  meats  and  fish,  however,  the  figures  for 
protein  "by  difference"  are  also  given.  Where  the  proteid  and 
non-proteid  nitrogenous  matter  have  been  estimated  in  a  food  material 
the  proportions  are  indicated  in  a  footnote. 

Fats. — Under  fats  is  included  the  total  ether  extract.  Familiar 
examples  of  fat  are  fat  of  meat,  fat  of  milk  (butter),  oil  of  corn,  olive 
oil,  etc.  The  ingredients  of  the  "ether  extract"  of  animal  and  vege- 
table foods  and  feeding-stuffs,  which  it  is  customary  to  group  roughly 
as  fats,  include  with  the  true  fats  various  other  substances,  as  fatty 
acids,  lecithins  (nitrogenous  fats),  and  chlorophylls. 

Carbohydrates. — Carbohydrates  are  usually  determined  by  differ- 
ence. They  include  sugars,  starches,  cellulose,  gums,  woody  fiber, 
etc.  In  manj'  instances  separate  determinations  of  one  or  more  of 
these  groups  have  been  made.  The  determinations  of  "fiber"  in 
vegetable  foods — i.  e.,  substances  allied  to  carbohydrates  but  insoluble 
in  dilute  acid  and  alkali,  and  somewhat  similar  to  woodv  fiber— -are 
given  in  a  separate  column. 

The  figures  in  parentheses  in  the  crude-fiber  column  show  the  num- 


CUTS  OF  MEATl^  805 

ber  of  analyses  in  which  the  liber  was  tletermined.  Tlie  figures  for 
"total  carbohydrates"  include  the  liber,  as  well  as  sugars,  starches, 
etc.  Where  the  sugars  or  starches  liave  been  determined  separately, 
footnotes  are  added  giving-  the  average  results. 

Ash  or  Mineral  Matters. — Under  this  head  are  included  ph()sj)hates, 
sulphates,  chlorids,  and  other  salts  of  potassium,  sodium,  magnesium, 
and  other  metallic  elements.  Where  analyses  of  the  mineral  matters 
have  been  found  they  are  added  in  the  form  of  footnotes.  These  re- 
sults usually  give  the  percentage  composition  of  the  ash  as  produced 
by  incineration  rather  than  the  proportions  in  which  the  different 
mineral  ingredients  occur  in  the  food  material. 

Fuel-value. — By  fuel-value  is  meant  the  number  of  calories  of  heat 
equivalent  to  the  energy  which  it  is  assumed  the  body  would  be  able  to 
obtain  from  one  pound  of  a  given  food  material,  provided  the  nutrients 
of  the  latter  were  completely  digested.  The  fuel  values  of  the  differ- 
ent food  materials  are  calculated  by  use  of  the  factors  of  Rubner, 
which  allow  4.1  calories  for  a  gram  of  protein,  the  same  for  a  gram 
of  carbohydrates,  and  9.3  calories  per  gram  of  fats.  These  amounts 
correspond  to  18.6  calories  of  energy  for  each  hundredth  of  a  pound 
of  protein  and  of  carbohydrates,  and  42.2  calories  for  each  hundredth 
of  a  pound  of  fat  in  the  given  food  material.  In  the  following  tables 
the  fuel-value  per  pound  has  been  calculated  by  use  of  these  factors. 
In  these  calculations  the  values  of  protein  by  factor  have  been  used 
in  all  cases  with  the  exception  of  salt  cod  and  hen's  eggs,  in  which  the 
value  of  protein  by  difference  was  used. 

CUTS  OF  MEAT 

The  methods  of  cutting  sides  of  beef,  veal,  mutton,  and  pork  into 
parts,  and  the  terms  used  for  the  different  "cuts,"  as  these  parts  are 
commonly  called,  vary  in  different  localities.  The  analyses  here  re- 
ported apply  to  cuts  as  indicated  by  the  following  diagrams.  These 
show  the  positions  of  the  different  cuts,  both  in  the  live  animal  and 
in  the  dressed  carcass  as  found  in  the  markets.  The  lines  of  division 
between  the  dift'erent  cuts  will  vary  slightly,  according  to  the  usage  of 
the  local  market,  even  where  the  general  method  of  cutting  is  as  here 
indicated.  The  names  of  the  same  cuts  likewise  vary  in  different  parts 
of  the  country. 

The  Cuts  of  Beef. — The  general  method  of  cutting  up  a  side  of  beef 
is  illustrated  in  Fig.  3,  which  shows  the  relative  position  of  the  cuts  in 
the  animal  and  in  a  dressed  side.  The  neck  piece  is  frequently  cut 
so  as  to  include  more  of  the  chuck  than  is  represented  by  the  diagrams. 
The  shoulder  clod  is  usually  cut  without  bone,  while  the  shoulder 
(not  indicated  in  diagram)  would  include  more  or  less  of  the  shoulder- 
blade  and  of  the  upper  end  of  the  fore  shank.  Shoulder  steak  is  cut 
from  the  chuck.     In  many  localities  the  plate  is  made  to  include  a,ll 


806        CHEMICAL  COMPOSITIOX  OF  AMERICAN  FOOD  MATERIALS 


the  parts  of  the  fore-quarter  designated  on  the  diagrams  as  brisket, 

cross-ribs,  plate  and  navel,  and  different  por- 
tions of  the  plate,  as  thus  cut,  are  spoken  of 
as  the  "brisket  end  of  plate"  and  "navel 
end  of  plate."  This  part  of  the  animal  is 
largely  used  for  corning.  The  ribs  are  fre- 
quently divided  into  first,  second,  and  third 
cuts,  the  latter  Ijing  nearest  the  chuck  and 
being  slightly  less  desirable  than  the  former. 
The  chuck  is  sometimes  subdivided  in  a  sim- 
ilar manner,  the  third  cut  of  the  chuck  be- 
ing nearest  the  neck.  The  names  applied  to 
different  portions  of  the  loin  vary  consider- 
ably in  different  localities.  The  part  near- 
est the  ribs  is  frequently  called  "small  end 
of  loin"  or  "short  steak."  The  other  end 
of  the  loin  is  called  "hip  sirloin"  or  "sir- 
loin." Between  the  short  and  the  sirloin  is 
a  portion  quite  generally  called  the  ' '  tender- 
loin," for  the  reason  that  the  real  tenderloin, 
the  very  tender  strip  of  meat  lying  inside  the 
loin,  is  found  most  fully  developed  in  this 
cut.  Porterhouse  steak  is  a  term  most  fre- 
quently applied  to  either  the  short  steak  or 
the  tenderloin.  It  is  not  uncommon  to  find 
the  flank  cut  so  as  to  include  more  of  the  loin 


Fig.  3. — Diagrams  of  cuts  of  beef:  1,  Xeck:  2,  ohiiok;  3,  ribs:  4,  shoulder- 
clod;  5,  fore-shank:  6.  brisket:  7,  cross-ribs;  8.  plate:  9,  navel:  10.  loin:  11, 
flank;  12,  rump:  13,  round;  14,  second-cut  round:  1.5.  hind-shank. —  (Atwater 
and  Bryant,  Bulletin  No.  28,  Office  of  Experiment  Stations,  United  States  De- 
partment of  Agriculture.) 


CUTii  OF  MEATS 


807 


than  is  indicated  in  tlie  figures,  in  which  case  the  upper  portion  is 
called  "flank  steak."  Tlie  larger  part  of  the  flank  is,  however,  very 
frequently  corned,  as  is  also  the  case  with  the  rump,  in  some  markets 
the  rump  is  cut  so  as  to  include  a  portion  of  the  loin,  which  is  then 
sold  as  "rump  steak."  The  portion  of  the  round  on  the  inside  of  the 
leg  is  regarded  as  more  tender  than  that  on  the  outside,  and  is  fre- 
quently preferred  to  the  latter.  As  the  leg  lies  upon  the  butcher's 
table  this  inside  of  the  round  is  usually  on  the  upper  or  top  side,  and 
is  therefore  called  "top  round."  Occasionally  the  plate  is  called  the 
''rattle." 

The  Cuts  of  Veal. — The  method  of  cutting  up  a  side  of  veal  differs 
considerably  from  that  employed  with  beef.  This  is  illustrated  by 
Fig.  4,  which  shows  the  relative  position  of  the  cuts  in  the  animal 
and  in  a  dressed  side.  The  chuck  is  much  smaller  in  proportion,  and 
frequently  no  distinction  is  made  between  the  chuck  and  the  neck. 
The  chuck  is  often  cut  so  as  to  include  considerable  of  the  portion 
here  designated  as  shoulder,  following  more  nearly  the  method  adopted 
for  subdividing  beef.  The  shoulder  of  veal  as  here  indicated  includes, 
besides  the  portion  corresponding  to  the 
shoulder  in  beef,  the  larger  part  of  what 
is  here  classed  as  chuck  in  the  adult  ani- 
~mal.  The  under  part  of  fore-quarter, 
corresponding  to  the  plate  in  the  beef,  is 


Fig  4— Diagrams  of  cuts  of  veal:  1,  Neck;  2,  chuck;  3,  shoulder;  4,  fore- 
shank;  5.  breast;  6,  ribs;  7.  loin;  8,  flank;  9,  leg;  10,  hind-shank.— (Auvater  and 
Bryant,  Bulletin  No.  28,  Office  of  Experiment  Stations,  United  States  Depart- 
ment of  Agriculture.) 

often  designated  as  breast  in  the  veal.  The  part  of  the  veal  corre- 
sponding to  the  rump  of  beef  is  here  included  with  the  loin,  but  is  often 
cut  to  form  part  of  the  leg.  In  many  localities  the  fore-  and  hind- 
shanks  of  veal  are  called  the  "knuckles." 

The  Cuts  of  Lamb  and  Mutton.— Fig.  5  shows  the  relative  position 
of  the  cuts  in  a  dressed  side  of  mutton  or  lamb  and  in  a  live  animal. 


808        CHEMICAL  COMPOSITION  OF  AMERICAN  FOOD  MATERIALS 

The  cuts  in  a  side  of  lamb  and  mutton  number  but  six,  three  in  each 
quarter.  The  chuck  includes  the  ribs  as  far  as  the  end  of  the 
shoulder-blades,  beyond  which  comes  the  loin.  The  flank  is  made  to 
include  all  the  under  side  of  the  animal.  Some  butchers,  however, 
make  a  larger  number  of  cuts  in  the  fore-quarter,  including  a  portion 
of  the  cuts  marked  "loin"  and  "chuck"  in  Fig.  5,  to  make  a  cut 
designated  as  "rib,"  and  a  portion  of  the  "flank"  and  "shoulder"  to 
make  a  cut  designated  as  "brisket."  The  term  "chops"  is  ordinarily 
used  to  designate  portions  of  either  the  loin,  ribs,  chuck  or  shoulder, 


Fig.  5. — Diagrams  of  cuts  of  lamb  and  mutton:  1,  Neck;  2,  chuck;  3,  shoul- 
der; 4,  flank;  5,  loin;  6,  leg. —  (Atwater  and  Bryant,  Bulletin  No.  28,  Office  of 
Experiment  Stations,  United  States  Department  of  Agriculture.) 

which  are  either  cut  or  "chopped"  by  the  butcher  into  pieces  suitable 
for  frying  or  boiling.  The  chuck  and  ribs  are  sometimes  called  the 
"rack." 

The  Cuts  of  Pork. — The  method  of  cutting  up  a  side  of  pork  differs 
considerably  from  that  employed  with  other  meats.  A  large  portion 
of  the  carcass  of  a  dressed  pig  consists  of  almost  clear  fat.  This  fur- 
nishes the  cuts  which  are  used  for  "salt  pork"  and  bacon.  Fig.  6 
illustrates  a  common  method  of  cutting  up  pork,  showing  the  relative 
position  of  the  cuts  in  the  animal  and  in  the  dressed  side.  The  cut 
designated  as  "back  cut"  is  almost  clear  fat,  and  is  used  for  salting 
and  pickling.     The  "middle  cut"  is  the  portion  quite  generally  used 


CITS  OF  MEATS 


809 


for  bacon  and  for  "lean  ends"  salt  pork. 
pickled  or  may  be  made  into  sausages. 


The  belly  is  salted  or 


Fig.  6. — Diagrams  of  cuts  of  pork:  1,  Head:  2.  shoulder:  ,3,  back:  4,  middle 
cut;  5,  belly:  6,  ham:  7,  ribs;  8,  loin. —  (Atvvater  and  Bryant,  Bulletin  No.  28, 
Office  of  Experiment  Stations,  United  States  Department  of  Agriculture.) 


Beneath  the  "back  cut"  are  the  ribs  and  loin, 
from  which  are  obtained  the  "spareribs," 
"chops."  and  roasting  pieces,  here  designated  by 
dotted  lines.  The  hams  and  shoulders  are  more 
frequently  cured,  but  are  also  sold  as  fresh  pork 
"steak."  The  tenderloin  proper  is  a  compara- 
tively lean  and  very  small  strip  of  meat  lying  un- 
der the  bones  of  the  loin  and  usually  weighing  a 
fraction  of  a  pound.  Some  fat  is  usually  trimmed 
off  from  the  hams  and  shoulders,  which  is  called 
"ham  and  shoulder  fat,"  and  is  often  used  for 
sausages,  etc.  What  is  called  "leaf  lard,"  at  least 
in  some  localities,  comes  from  the  inside  of  the 
back.     It  is  the  kidney  fat. 

As  stated  above  cuts  as  shown  in  the  diagrams 
herewith  correspond  to  those  of  which  analyses  are 
reported  in  the  tables  beyond,  but  do  not  attempt 
to  show  the  different  methods  of  cutting  followed 
in  markets  in  different  parts  of  the  United 
States. 


Note. — Dividing  the  calories  per  pound  by  4.5  will  give  the  approximate  num- 
ber of  calories  per  100  grams.     See  also  additional  tables  in  front  of  book. 


THE  CHEMICAL  COMPOSITION  OF  AMERICAN  FOOD 

MATERIALS 

(The  figures  given  are  the  averages  in  each  instance.) 


Food  materials. 


Animal  Food, 
beef,  fresh. 

Brisket,  medium  fat- 
Edible  portion 

As  purchased  .       .   , 

Chuck,  including  shoulder, 
lean- 
Edible  portion 

As  purchased       .       . 

Chuck,  including  shoulder, 
medium  fat- 
Edible  portion 

As  purchased 

Chuck,  including  shoulder, 
fat- 
Edible  portion 

As  purchased 

Chuck,  including  shoulder, 
very  fat— 

Edible  portion 

As  purchased 

Chuck  rib,  lean- 
Edible  portion 

As  purchased 

Chuck  rib,  medium  fat- 
Edible  portion 

As  purchased 

Chuck  rib,  fat- 
Edible  portion 

As  purchased 

Flank,  very  lean- 
Edible  portion 

As  purchased 

Flank,  lean — 

Edible  portion 

As  purchased 

Flank,  medium  fat- 
Edible  portion 

As  purchased 

Flank,  fat- 
Edible  portion 

As  purchased 

Flank,  very  fat- 
Edible  portion 

As  purchased 

Loin,  very  lean — 

Edible  portion 

As  purchased 

Loin,  lean- 
Edible  portion 

As  purchased 

Loin,  medium  fat — 

Edible  portion 

As  purchased       


as 


Protein. 


Perct.  Perct.  Perct. 


23.3 


54.6 
41.6 


71.3 
19.5      57.4 


15.2 

14.7 

22.8 
22.7 
16.3 

io.2 

'3.5 
1.4 

io.2 

3.3 
'6.0 
23.0 
13.1 
13.3 


68.3 
57.9 


53.2 
40.8 


71.3 
55.1 


62.7 
52.6 


52.0 
46.8 


70.7 
68.2 


67.8 
66  9 


60.2 
54.0 


54.2 

52.4 


34.7 
33.0 


70.8 
54.6 


67.0 
58.2 


60.6 
52.5 


15.8 
12.0 


20.2 
16.3 


19.6 
16.6 


62.3  ;    185 
53.3  !    15.9 


17.2 
13.3 


19.5 
15.1 


18.5 
15.5 


16.5 
14.8 


25.9 
24.9 


20.8 
20.5 


18.9 
17.0 


17.1 
16.5 


14.0 
13.2 


24.6 
18.8 


19.7 
17.1 


18.5 
16.1 


Per  ct 

16.0 
12.2 


19.5 
15.7 


18.9 
16.0 


18.0 
15.4 


16.9 
13.0 


19.4 
15.0 


18.3 
15.3 


16.1 
14.4 


24.8 
23.9 


19.9 
19.7 


17.9 
16.1 


16.6 
16.2 


12.8 
12.0 


24.2 
18.5 


19.3 
16.7 


18.2 
15.8 


Perct. 

28.5 
22.3 


11.9 
10.1 


18.8 
15.9 


29.0 
22.7 


18.0 
15.0 


31.1 
27.9 


11.3 
11.0 


21.0 
19.0 


28.4 
27.3 


51.8 
48.3 


12.7 
11.1 


20.2 
17.5 


J3  aa 
U  IS/ 

H 


Perct.  Perct. 

0.9 
0.6 


1.0 
0.8 


0.9 
0.8 


0.9 
0.7 


0.9 
0.7 


;  1.0 
I  0.8 


1.0 
0.8 


0.8 
0.7 


1.2 
1.1 


1.0 
1.0 


0.9 

0.7 


0.8 
0.8 


0.7 
0.7 


1.3 

0.9 


1.0 
0.9 


1.0 

0.9 


•a 

•§§ 

> 

So. 


Cats. 
1495 
1166 


720 
380 


865 
735 


1135 
965 


15S5 
1205 


715 

550 


1105 
920 


1620 
1455 


620 
605 


865 
845 


1240 

1115 


1515 
1460 


2445 
2275 


615 

475 


900 

786 


1190 
1040 


810 


CHEMICAL  COMPOSITION  OF  AMERICAN  FOOD  MATFIUALS       811 


Food  materials. 


as 

3  OS 


Animal  Food  {Continued) 
BEEF,  FKESH  {Continued). 

Loin,  fat — 

Edible  portion 

As  purcliased 

Loin,  very  fat- 
Edible  portion 

As  purchased 

Loin,  boneless  strip,  as  pur- 
chased ' 

Loin,  sirloin  butt,  as  purch'd' 

Loin,    tenderloin,    as     pur- 
chased • 

Neck,  very  lean — 

Edible  p'ortion 

As  purchased 

Neck,  lean — 

Edible  portion 

As  purchased 

Neck,  medium  fat — 

Edible  portion 

As  purchased 

Plate,  very  lean— 

Jtidible  portion 

As  purchased 

Plate,  lean- 
Edible  portion 

As  purchased 

Plate,  medium  fat- 
Edible  portion 

As  purchased 

Plate,  fat- 
Edible  portion     

As  purchased 

Ribs,  very  lean- 
Edible  portion 

As  purchased 

Ribs,  lean — 
Edible  portion  . 
As  purchased    . 

Ribs,  medium  fat 
Edible  portion  . 
As  purchased    . 

Ribs,  fat- 
Edible  portion  . 
As  purchased 

Rib  rolls,  very  lean,  as  pur- 
chased   

Rib  rolls,  lean,  as  purchased 

Rib  rolls,  medium  fat,  as  pur- 
chased   

Rib  rolls,  fat,  as  purchased  . 

Rib  trimmings,  all  analyses — 
Edible  portion  .   .   . 
As  purchased    .  .  . 

Round,  very  lean — 
Edible  portion  .   .   . 
As  purchased    .   .  . 

Round,  lean — 
Edible  portion  .   .   . 
As  purchased    .   .   . 

Round,  medium  fat — 
Edible  portion  .  .  . 
As  purchased    .  .   . 

Round,  fat — 
Edible  portion  .   .   . 
As  purchased   .  .  . 


I 


Perot. 
io, 


Perct. 

54.7 
4U.2 

49.7 
44.9 

66.3 
62.5 

59.2 

73.2 
40.7 

70.1 
49.5 

63.4 
45.9 

69.1 
43.0 

65.9 
54.4 

54.4 
45.3 

45.2 
38.0 

70.9 
54.2 

67.9 
52.6 

55.5 
43.8 

48.5 
39.6 

73.7 
69.0 

63.9 
51.5 

54.7 
35.7 

73.6 
65.9 

70.0 
64.4 

65.5 
60.7 

60.4 
54.0 


Protein. 


Perct. 

17.5 
15.7 

17.8 
16.0 

17.8 
19.7 

16.2 

22.5 
12.5 

21.4 
15.1 

20.1 
14.5 

22.8 
13.6 

15.6 
13.0 

16.5 
13.8 

14.6 
12.2 

25.0 
19.4 

19.6 
15.2 

17.5 
13.9 

15.0 
12.7 

20.8 
20.2 

19.3 
17.2 

16.9 
11.0 

22.6 
20.2 

21.3 
19.5 

20.3 
19.0 

19.5 
17.5 


Perct 

16.8 
15.0 

17.1 
15.5 

16.2 
18.9 

15.6 

22.5 
12.2 

20.5 
14.4 

19.2 
13.9 

22.1 
13.2 

14.6 
12.2 

15.7 
13.1 

14.2 
11.9 

24.4 
18.9 

19.1 

14.8 

17.0 
13.5 

15.2 
12.4 

20.3 
19.5 

18.5 
16.4 

16.1 
10.5 

22.3 
19.9 

21.0 
19.2 

19.8 
18.3 

19.1 
17.1 


Per  ct. 

27.6 
24.8 

32.3 
29.1 

16.7 
17.7 


3.2 
2.2 


8.4 
5.9 


16.5 
11.9 


7.7 
5.7 


18.8 
15.5 


29.1 
24.4 


39.8 
33.5 


12.0 
9.3 


26.6 
21.2 


35.6 
30.6 


5.0 
10.5 


16.7 
31.3 


28.4 
19.2 


7.9 
7.3 


13.6 
12.8 


19.5 
16.1 


Perct 


T3 

(ua 

3  3 

«0. 

■  Pn 

.a 

3  0« 

< 

[^ 

Perct 

0.9 
0.8 

0.9 
0.8 

0.8 
0.9 

0.8 

1.1 
0.6 

i.n 
0.7 

0.9 
0.7 

1.1 

0.7 

0.7 
0.6 

0.8 
0.4 

0.8 
0.6 

1.2 
0.9 

1.0 

0.7 

0.9 
0.7 


Gals. 

1490 
1305 

1695 
1625 

1035 
1115 

1330 

555 
325 

750 
530 

1070 
770 

750 
495 

1085 
895 

1535 
1285 

1950 
1640 

615 
475 

870 
675 

1450 
1155 


0.7 
0.6 

1780 
1525 

1.0 
1.0 

600 

820 

0.9 
0.8 

1065 
1640 

0.8 
0.5 

1515 
1015 

1.3 
1.2 

540 
475 

1.1 
1.0 

730 
670 

1.1 
1.0 

950 
895 

1.0 
0.8 

1185 
.1005 

1  All  loin  parts  are  included  under  analyses  of  "  loin." 


812        CHEMICAL  COMPOSITIOy  OF  AM  ERIC  AX  FOOD  MATERIALS 


Food  materials. 


<« 

o 

CA 

a> 

a 

OS 

a 

3 

a 

z 

Animal  Food  (Continued). 
BEEF,  FRESH  (Continued). 
Round,  very  fat- 
Edible  portion  

As  purchased 

Round,  second  cut- 
Edible  portion 

As  purchased 

Rump,  very  lean- 
Edible  portion 

As  purchased 

Rump,  lean- 
Edible  portion 

As  purchased 

Rump,  medium  fat- 
Edible  portion 

As  purchased , 

Rump,  fat- 
Edible  portion 

As  purchased 

Shank,  fore,  very  lean- 
Edible  portion 

As  purchased 

Shank,  fore,  lean- 
Edible  portion 

As  purchased 

Shank,  fore,  medium  fat- 
Edible  portion 

As  purchased 

Shank,  hind,  lean — 

Edible  portion 

As  purchased 

Shank,  hind,  medium  fat- 
Edible  portion 

As  purchased 

Shoulder     and     clod,    very 
lean— I 

Edible  portion 

As  purchased 

Shoulder  and  clod,  lean- 
Edible  portion 

As  purchased 

Shoulder  and  clod,  medium 
fat- 
Edible  portion  

As  purchased 

Shoulder  and  clod,  fat- 
Edible  portion 

As  purchased 

Forequarter,  very  lean- 
Edible  portion 

As  purchased 

Forequarter,  lean- 
Edible  portion 

As  purchased 

Forequarter,  medium  fat- 
Edible  portion 

As  purchased 

Hind  quarter,  very  lean — 

Edible  portion 

As  purchased 

Hind  quarter,  lean- 
Edible  portion 

As  purchased 

Hind  quarter,  medium  fat- 
Edible  portion 

As  purchased 


<u 

u 

% 

^ 

Per  ct. 

Per  el. 

55.9 

il.4 

49.6 

Protein. 


.    .     I    69.8 
19.5      56.2 


14.3 
i4.0 
20.7 
23.0 
44.1 
36.5 
36.9 
58.5 
53.9 

23.3 

18.8 

16.4 

ii.'g 

30.3 
22.3 
U.l 
21.0 
16.6 
15.7 


71.2 
60.9 


65.7 
56.6 


56.7 
45.0 


47.1 
36.2 


74.4 
41.6 


71.5 
45.4 


67.9 
42.9 


72.5 
30.1 


67.8 
31.3 


76.1 
58.3 


73.1 
59.4 


68.3 
56.8 


60.4 

52.8 


74.1 
51.5 


68.6 
53.3 


60.4 
49.1 


72.0 
56.9 


66.3 
55.3  I 


59.8 
50.4 


Per  ct. 

18.2 
16.1 

20.4 
16.4 

23.0 
19.5 

20.9 
19.1 

17.4 
13.8 

16.8 
12.9 

22.1 
12.3 

22.0 
14.6 

20.4 
12.8 

21.9 
9.1 

20.9 
9.6 


21.3 
16.3 


20.4 
16.4 


19.6 
16.4 


19.5 
17.7 


22.1 
15.4 


18.9 
14.7 


17.9 
14.5 


24.0 
19.0 


20.0 
16.7 


18.3 
15.4 


Per  ct. 

17.1 
15.2 

20.5 
16.5 

22.5 
19.1 

19.6 
17.5 

16.9 
13.4 

16.4 
12.6 

21.7 
12.1 

21.4 
13.6 

19.6 
12.3 


19.8 
9.1 


21.5 
16.5 


20.4 
16.5 


19.3 
16.1 


18.8 
16.7 


21.3 
14.8 


18.4 
14.3 


17.3 
14.0 


123.3 
18.4 


19.3 
16.1 


17.7 
14.9 


Per  ct. 

26.2 
23.1 

8.6 
6.9 

5.1 
4.6 

13.7 
11.0 

25.5 
20.2 

35.7 
27.6 

2.8 
1.6 

6.1 
3.9 

11.6 
7.3 

5.4 
2.2 

11.5 
5.3 


Per  ct. 


11.3 
9.8 


19.8 
17.7 


3.6 
2.7 


12.2 
9.5 


21.4 
15.5 


13.4 
11.2 


21.6 
18.3 


Per  ct 

0.8 
0.7 


1.1 
0.9 


1.2 
1.1 


1.0 

0.9 


0.9 

0.7 


1.0 
0.6 


0.9 
0.6 


1.0 
0.4 


0.9 
0.4 


1.1 

0.9 


"3  o 


Cols. 
1445 
1275 

740 
595 

645 
555 

965 
820 

1400 
1110 

1820 
1405 

530 
295 

665 
425 

870 
545 

635 
260 

875 
405 


450 
345 


605 
490 


840 
720 


1200 
1075 


1.0 
0.9 

565 
400 

0.8 
0.6 

865 
675 

0.9 
0.7 

1235 
1010 

1.2 
0.9 

595 
470 

1.0 
0.8 

936 

785 

0.9 
0.7 

1250 
1060 

>  The  "  clod  "  usually  contains  no  refuse. 


CHEMICAL  COMPOSITIOX  OF  AMf-JRICAX  FOOD  MATKIUALH        813 


Animal  Food  (Continued) 
BEEF,  FRESH  (Continued). 

Sides,  very  lean- 
Edible  portion 

As  purchased 

Sides,  lean- 
Edible  portion 

As  purchased       

Sides,  medium     t 

Edible  poriioh      

As  purchased 

BEEF  ORGANS. 

Brain,  edible  portion  .  .  . 
Heart,  edible  portion  .  .  . 
"Kidney,  edible  portion  .  . 
Beef  liver,  edible  portion  . 
Lungs,  as  purchased  .  .  . 
Marrow,  as  purchased  .  .  . 
Sweetbreads,  as  purchased 
Suet,  as  purchased  .... 
Tongue — 

Edible  portion 

As  purchased 


BEEF,  COOKED. 

Scraps,  as  purchased    .  .  .   . 

Roast,  as  purchased 

Round  steak,  fat  removed,  as 

purchased 

Loin    steak,    tenderloin, 

broiled,  edible  portion  . 
Sandwich  meat,  as  purchased 

BEEF,  CANNED. 

Boiled  beef,  as  purchased  . 
Cheek,  ox,  as  purchased 
Chili-con-carne,  as  purch'd 
CoUops,  minced,  as  purch'd 

Corned  beef 

Dried  beef,  as  purchased    . 
Kidneys,  stewed,  as  purch'd 
Roast  beef,  as  purchased    . 
Rump  steak,  as  purchased 
Sweetbreads,  as  purchased 
Tongue,  ground,  as  purch'd 
Tongue,  whole,  as  purchased 
Tripe,  as  purchased 


BEEF,  CORNED  AND  PICKLED 

Flank- 
Edible  portion 

As  purchased 

Rump- 
Edible  portion 

As  purchased 

Mess  beef,  salted- 
Edible  portion 

As  purchased 

Corned  beef- 
Edible  portion 

As  purchased 

Tong;ues,  pickled — 

Edible  portion 

As  purchased 

Tripe,  as  purchased 


12.1 

'e.b 

10.0 
'8.4 
6.0 


51.8 
6G.1 
75.4 
72.3 
51.8 
44.8 
71.9 
58.9 
56.3 


69.0 
49.9 
51.3 
74.6 

20.2 
21.4 
19.5 
16.8 

49.9 
43.7 

14.6 
12.9 

58.1 
54.5 

15.3 
14.3 

37.0 
33.0 

12.fi 
11.2 

53.6 
49.2 

1.5.6 
14.3 

62.3 
.58.9 
86.5 

12.8 
11.9 
11.7 

2110 
1890 


1.395 
1271 


12.5 
11.6 
11.8 


4.7  1105 
4.3  1030 
0.3     I     270 


814        CHEMICAL  COMPOSlTlOy  OF  AMERICAN  FOOD  MATERIALS 


Food  materials 


Animal  Food  (Continued). 

BEEF,  DRIED,  ETC. 

Dried,  salted,  and  smoked- 
Edible  portion 

As  purchased 

VEAL,  FRESH. 

Breast,  lean- 
Edible  portion 

As  purchased       

Breast,  medium  fat- 
Edible  portion 

As  purchased 

Chuck,  medium  fat — 

Edible  portion 

As  purchased 

Flank,  medium  fat,  as  pur- 
chased   

Leg,  lean- 
Edible  portion 

As  purchased 

Leg,  medium  fat— 

Edible  portion 

As  purchased 

Leg,  cutlets- 
Edible  portion 

As  purchased 

Loin.  lean- 
Edible  portion  

As  purchased 

Loin,  medium  fat- 
Edible  portion 

As  purchased 

Loin,  fat  — 

Edible  portion 

As  purchased 

Neck- 

Edible  portion 

As  purchased 

Eib,  medium  fat- 
Edible  portion 

As  purchased 

Rib.  fat- 
Edible  portion 

As  purchased 

Shank,  fore — 

Edible  portion 

As  purchased 

Shank,  hind,  medium  fat — 

Edible  portion 

As  purchased 

Shoulder,  lean — 

Edible  portion 

As  purchased 

Shoulder  and  flank,  medium 
fat- 
Edible  portion 

As  purchased 

Forecjuarter— 

Edible  portion 

As  purchased 

Hind  quarter- 
Edible  portion 

As  purchased 

Side,  with  kidney,  fat  and 
tallow- 
Edible  portion 

As  purchased 


Protein. 


Per  ct. 


6 
6 


2     1 
2     I    18, 


6 

6     !    20, 


Per  ct.: Per  ct. 


54.3 
53.7 


70.3 
54.0 


66.4 
52.7 


73.3 
59.5 


68.9 


73.5 
66.8 


70.0 
60.1 


70.7 
68.3 


73.3 
57.1 


69.0 
57.6 


61.6 
50.4 


72.6 
49.9 


72.7 
54.3 


60.9 
46.2 


74.0 
44.1 


74.5 
27.8 


73.4 
59.9 


65.2 
50.2 


71.7 
54.2 


30.0 
26.4 


21.2 
15.7 


19.4 
15.6 


19.7 
16.0 


21.3 
19.4 


20.2 
15.5 


20.3 
20.1 


20.4 
15.9 


19.9 
16.6 


18.7 
15.3 


20.3 
13.9 


20.7 
15.5 


18.7 
14.2 


20.7 
12.2 


20.7 

7.7 


20.7 
16.9 


19.7 
15.1 


20.0 
15.1 


it:  <o 
pq 


70.9  !    20.7 
56.2  !    16.2 


71.3 

56.2 


20.2 
15.6 


Per  ct. 

29.7 
25.8 


20.7 
16.1 


18.8 
14.9 


19.2 
15.6 


21.2 
19.3 


19.8 
16.9 


20.5 
19.8 


19.9 
15.6 


19.2 
16.0 


18.5 
15.1 


19.5 
13.3 


20.1 
15.0 


18.8 
14.2 


19.8 
11.8 


19.9 
7.4 


20.7 
16.9 


19.3 
14.9 


19.4 
14.6 


19.8 
15.7 


19.6 
15.1 


Per  ct.  Per  ct. 

6.5  '   (3).4 
6.9 


8.0 
6.2 


1.S.8 
11.0 


6.5 
5.2 


7.7 
7.5 


5.6 
4.4 


10.8  I 
9.0 


18.9 
15.4 


6.9 
4.6 


19.3 
14.5 


4.6 
1.7 


14.4 
11.0 


8.1 
6.3 


Per  ct. 

9.1 
8.9 


1.0 
0.7 


1.0 
0.8 


1.0 
0.8 


1.0 


1.2 
l.l 


1.2 
0.9 


1.1 
1.0 


1.2 
0.9 


1.0 
0.9 


1.0 

0.8 


1.0 
0.7 


1.1 
0.8 


1.0 
0.8 


1.0 
0.6 


1.0 
0.4 


1.3 
1.0 


l.t 
0.9 


0.9 
0.7 


1.0 

0.8 


1.0 
0.8 


CHEMICAL   COUroSITIOX   OF  AMh'h'lCAX  FOOD    MATFIH AL.S        815 


Food  materials. 


Animal  Food  (Continued). 

VEAL  ORGANS. 

Kidneys,  a.s  purchased    .   .   . 
Liver,  as  purchased 

LAMB,  FRESH. 

Breast  or  chuck — 

Edible  portion 

As  purchased 

Leg,  hind,  medium  fat — 

Edible  portion 

As  purchased 

Loin,    without    kidney   and 
tallow  — 

-Edible  portion 

As  purchased 

Shoulder- 
Edible  portion 

As  purchased 

Forequarter — 

Edible  portion 

As  purchased 

Hind  quarter- 
Edible  portion 

As  purchased 

Side,  without  tallow — 

Edible  portion 

As  purchased 

LAMB,  COOKED. 

Chops, broiled,  edible  portion 

MUTTON,  FRESH. 

Chuck,  medium  fat- 
Edible  portion 

As  purchased 

Chuck,  fat- 
Edible  portion 

As  purchased 

Flank,  medium  fat- 
Edible  portion  

As  purchased 

Flank,  very  fat,  as  purchased 

Leg,  hind,  lean- 
Edible  portion 

As  purchased 

Leg,  hind,  medium  fat — 

Edible  portion 

As  purchased    .  .  .   .   . 

Loin,  without  kidney  or  tal- 
low, medium  fat — 

Edible  portion 

As  purchased 

Loin,  without  kidney  or  tal- 
low, fat — 

Edible  portion 

As  purchased 

Neck,  medium  fat- 
Edible  portion 

As  purchased 

Shoulder,  medium  fat — 

Edible  portion 

As  purchased 

Forequarter — 

Edible  portion 

As  purchased 

Hind  quarter- 
Edible  portion 


S  C4 


Per  ct. 

ig.'i 

17.4 

i4.'8 
20.3 
8.8 
5.7 
9.3 


21.3 
6.5 
9.9 

6.8 
8.4 

16.0 

il.V 
27.4 
22.5 
21.2 


75.8 
73.0 


56.2 
45.5 


63.9 
52.9 


53.1 
45.3 


51.8 
41.3 


55.1 
44.7 


60.9 
51.3 


58.2 
47.0 


50.9 
39.9 

40.6 
33.8 

46.2 
39.0 
28.9 

67.4 
56.1 

62.8 
51.2 


50.2 
42.0 


58.1 
42.1 


61.9 
47.9 


52.9 
41.6 


Protein. 

i 

to 
X 

Per  ct. 

Per  ct. 

Per  ct.  J 

16.9 
19.0 

16.5 
20.4 

6.4 
5.3 

19.1 
15.4 

19.2 
15.5 

23.6 
19.1 

19.2 
15.9 

18.5 
15.2 

16.5 
13.6 

18.7 
16.0 

17.6 
15.0 

28.3 
24.1 

18.1 
14.4 

17.5 
14.0 

29.7 
23.6 

18.3 
14.9 

18.1 
14.7 

25.8 
21.0 

19.6 
16.5 

19.0 
16.0 

19.1 
16.1 

17.6 
14.1 

17.6 
14.2 

28.1 

18.7 

21.7 

21.2 

29.9 

15.1 
11.9 

14.6 
11.5 

33.6 
26.7 

13.9 
11.6 

13.7 
11.5 

44.9 
37.5 

15.2 
13.8 
10.7 

14.8 
13.6 
10.7 

38.3 
36.9 
59.8 

19.8 
16.5 

19.1 
15.9 

12.4 
10.3 

18.5 
15.1 

18.2 
14.9 

18.0 
14.7 

16.0 
13.5 

15.9 
13.0 

83.1 

28.3 

14.7 
13.0 

14.2 
12.5 

41.7 
36.8 

16.9 
12.3 

16.3 
11.9 

24.6 
17.9 

17.7 
13.7 

17.3 
13.4 

19.9 
1.5.5 

15.6 
12..S 

l.'i.S 
12.0 

30.9 
24.5 

16.7 

16.3 

28.1 

Per  ct. 


Per  ct. 
1.3 
1.3 


1.0 
0.8 


1.1 
0.9 


1.0 

0.8 


1.0 
0.8 


1.0 
0.8 


1.0 
0.9 


0.9 
0.6 

0.8 
0.7 

0.7 
0.6 
0.6 

1.1 

0.9 

1.0 
0.8 


0.8 
0.7 


0.8 
0.7 


1.0 

0.7 


0.9 
0.7 


0.9 
0.7 


Calt. 

585 
576 


1350 
1090 


1055 
870 


1540 
1315 


1590 
1265 


1430 
1165 


1170 

985 


1300 
1055 


1665 


1700 
1350 

2155 
1800 

1900 
1815 
2725 

890 
740 

1105 
900 


1695 
1445 


2035 
1795 


1355 
985 


1170 
910 


1.595 
1265 


816        CHEMICAL  COMPOSITIOy    OF  AMERICAN  FOOD  MATEKIALH 


Food  materials. 


ANIMAL  Food  (Continued). 
MUTTON,  FRESH  (Contimied) . 

Hind  quarter  (Continued)— 
As  purchased 

Side,  including  tallow- 
Edible  portion 

As  purchased 

Side,  not  including  tallow — 

Edible  portion 

As  purchased 

MUTTON,  COOKED. 

Mutton,  leg  roast,  edible  por- 
tion     

MUTTON,  ORGANS. 

Heart,  as  purchased     .... 
Kidney  fat,  as  purchased  .   . 

Liver,  as  purchased 

Lungs,  as  purchased     .... 

MUTTON,  CANNED. 

Corned,  as  purchased  .... 
Tongue,  as  purchased  .... 

PORK, FRESH. 

Chuck  ribs  and  shoulder- 
Edible  portion 

As  purchased 

Flank- 
Edible  portion 

As  purchased 

Ham,  fresh,  lean — 

Edible  portion 

As  purchased 

Ham,  fresh,  medium  fat- 
Edible  portion 

As  purchased 

Ham,  fresh,  fat — 

Edible  portion 

As  purchased 

Head- 
Edible  portion 

As  purchased 

Head  cheese,  edible  portion 

Loin  (chops),  medium  fat — 

Edible  portion 

As  purchased 

Loin  (chops),  fat- 
Edible  portion 

As  purchased 

Loin,  tenderloin,  as  purch'd 

Middle  cuts — 

Edible  portion 

As  purchased 

Shoulder — 

Edible  portion 

As  purchased 

Side,  lard  and  other  fat  in- 
cluded— 

Edible  portion 

As  purchased 

Side,  not  including  lard  and 
kidney — 

Edible  portion 

As  purchased 

Clear  backs — 

Edible  portion 

As  purchased. 


3  oj 


Per  cl. 


18.1 


11.2 

ii.'s 

'5.'7 


Per  ct. 
45.4 


54.2 
45.4 


53.6 
43.3 


69.5 

3.4 

61.2 

75.9 


45.8 
47.6 


51.1 
41.8 

59.0 
48.5 

60.0 
59.4 

53.9 
48.0 

38.7 
33.6 

45.3 
13.8 
43.3 

52.0 
41.8 

41.8 
34.8 
66.5 

48.2 
38.6 

51.2 
44.9 


29.4 
26.1 


34.4 
30.4 


25.1 
23.7 


Protein. 


Per  ct. 
13.8 


16.3 
13.0 


16.2 
13.0 


te  6 


Per  cl. 
13.5 


16.0 
12.7 


15.8 
12.7 


25.0      25.3 


16.9 

1.8 

23.1 

20.2 


28.8 
24.4 


17.3 
14.1 

18.5 
15.1 

25.0 
24.8 

15.3 
13.5 

12.4 
10.7 

13.4 
4.1 
19.5 

16.6 
13.4 

14.5 
11.9 
18.9 

15.7 
12.7 

13.3 
12.0 


9.1 
8.6 


6.4 
6.0 


17.0 
1.1 


20.1 


27.2 
23.6 


16.9 
13.8 

17.8 
14.2 

24.3 
24.2 

16.4 
14.6 

10.6 
9.2 

12.7 
3.8 
16.9 

16.9 
13.5 

13.1 
10.9 
19.5 

14.8 
12.1 

13.8 
12.2 


9.8 

8.6 


6.9 
6.4 


Per  ct 
23.2 


28.9 
23.1 


29.8 
24.0 


12.6 

95.4 

9.0 

2.8 


22.8 
24.0 


31.1 
25.5 

22.2 
18.6 

14.4 
14.2 

28.9 
25.9 

50.0 
43.5 

41.3 

13.8 
33.8 

30.1 
24.2 

44.4 
37.2 
13.0 

36.3 

28.9 

34.2 
29.8 


61.7 

54.8 


55.3 
49.0 


67.6 
63.8 


Per  ct. 


Perct.  Cats. 
0.7     ;  1235 


0.9 
0.7 


0.8 
0.7 


0.9 
0.1 

1.7 
1.2 


4.2 
4.8 


0.9 
0.8 

1.0 
0.7 

1.3 
1.3 

0.8 
0.8 

0.7 
0.5 

0.7 
0.2 
3.3 

1.0 
0.8 

0.7 
0.6 
1.0 

0.7 
0.7 

0.8 
0.7 


0.4 
0.4 


0.5 
0.5 


0.4 
0.4 


CHEMICAL  COMPOSITIOX  OF  AMERICAN  FOOD  MATF RIALS        817 


Food  materials. 


Akimal  Food  (Continued) 
PORK,  FKESH  (Continued). 
Clear  bellies- 
Edible  portion  .... 
As  purchased    .... 
Back  fat,  as  purchased 
Belly  fat,  as  purchased 
Bam  fat,  as  purchased 
Jowl  fat,  as  purchased 
Feet- 
Edible  portion 
As  purchased 
Tails- 
Edible  portion 
As  purchased 
Trimmings — 
Edible  portion 
As  purchased 

FORK  ORGANS,  ETC. 

Kidneys,  as  purchased 
Liver,  as  purchased  .  . 
Marrow,  as  purchased  . 


PORK,  PICKLED,  SALTED,  AND 
SMOKED. 

Ham,  smoked,  lean- 
Edible  portion 

As  purchased       

Ham,  smoked,  medium  fat- 
Edible  portion 

As  purchased 

Ham,  smoked,  fat — 

Edible  portion 

As  purchased    ...... 

Ham,  smoked,  boiled,  as  pur- 
chased ....     ■  .  . 

Ham,  smoked,  fried,  as  pur- 
chased   

Ham,  boneless,  raw — 

Edible  portion 

As  purchased 

Ham,  luncheon,  cooked — 

Edible  portion 

As  purchased       

Shoulder,  smoked,  medium 
fat- 
Edible  portion 

As  purchased       

Shoulder,  smoked,  fat- 
Edible  portion 

As  purchased  

Pigs'  tongues,  pickled- 
Edible  portion 

As  purchased 

Pigs'  feet,  pickled — 

Edible  portion 

As  purchased 

Dry-salted  backs — 

Edible  portion 

As  purchased    ....... 

Dry-salted  bellies- 
Edible  portion 

As  purchased 

Salt  pork,  clear  fat,  as  pur- 
cnased 

Salt  pork,  lean  ends- 
Edible  portion  

As  purchased 


as 

3  at 
S5 


Perct. 
6.2 


7.4 


11.5 
13.6 
3.4 

3.3 
2.1 

i8.'2 
20.0 

3.2 
35.5 

8.1 
'8.2 

il.2 


Perct.  Perct 


Protein. 


314 

29.5  I 

7.7 
13.8 

9.1 
16.0 

55.4 
14.3 

17.4 
15.0 

23.3 
21.6 


6.9 
6.5 
3.6 
5.2 
3.5 
5.9 

15.8 
4.1 

4.8 
4.1 

5.4 

5.0 


Perct. 

7.8 
7.3 
2.3 
4.1 


17.5 
4.5 


5.2 
4.5 


6.2 
5.7 


53.5 
47.2 


40.3 
34.8 


27.9 
25.2 


51.3 
36.6 


50.1 
48.5 


49.2 
48.1 


45.0 
36.8 


26.5 
21.4 


58.6 
56.8 


68.2 
44.6 


17.3 
15.9 


17.7 
16.2 


19.9 
17.6 


19.8  !    20.2 
17.5      17.9 


16.3 
14.2 


14.8 
12.4 


20.2 
22.2 


14.9 
14.3 


22.5 
22.1 


15.9 
13.0 


15.1 
12.1 


17.7 
17.1 


16  3 
10.2 


1.9 


8.4 
7.4 


16.1 
14.0 


16.1 
14.2 


20.2 
24.4 


15.4 
14.9 


24.0 
23.5 


15.8 
12.9 


14,7 
11.8 


18.0 
17.5 


16.1 
10.0 


7.2 
6.5 


6.7 
6.2 


2.0 


Per  a. 

60.4 
56.6 
89.9 
81.9 
88.0 
78.8 

26.3 
6.9 

77.1 
66.9 

70.2 
65.0 


77.8  15.5  16.2  4.8 
71.4  21.3  !  21.3  4.5 
14.6        2.3  i     4.2      81.2 


20.8 
18.5 


38.8 
33.4 


52.3 
53.7 


22.4 
33.2 


28.5 
27.5 


21.0 
20.6 


32.5 
26.6 


53.6 
42.6 


19.8 
19.1 


14.8 
9.3 


72.7 
66.8 


72.2  I 
66.2  i 


67.1 
59.6 


Perct. 


Perct. 

0.4 
0.4 
01 
0.2 
0.2 
0.2 

o.,s 

0.2 

0.3 
0.3 

0.3 
0.3 


1.2 
1.4 


5..'i 
4.9 


4.8 
4.2 


3.7 
3.5 


6.1 

5.8 


6.0 
5.8 


5.8 
5.7 


6.7 
5.5 


5.2 
4.2 


3.6 
3.4 


0.9 
0.6 


CaU. 

2675 
2510 
3860 
3555 
3780 
3435 

1405 
365 

3340 
2900 

3060 
2835 


490 

615 

3470 


1245 
1106 


1940 
1675 


2485 
2495 


1320 
1815 


1480 
1425 


1305 
1280 


1665 
1365 


2545 
2020 


1165 
1125 


9.30 

585 


2.8 
2.7 

3210 
2950 

34 

3.2 

3200 
2935 

3.9 

3670 

5.7 
5.1 

2985 
265» 

818        CHEMICAL  COMPOSITIOX  OF  AMERICA^'  FOOD  MATERIAL^ 


Protein. 

6  . 

■d 

**-*   r» 

XI  CO 

aj  0 

°s 

fl^ 

rt-2 

^g 

Food  materials. 

s5 

•2^ 

i 

u 

CO 

£  ■ 
tea  0) 

gg 

I—  0 

3  « 

c3 

X 

03 

si  >> 

.d 

30. 

Z 

03 

^ 

z 

n 

fe 

H 

< 

f-^ 

Animal  Food  {Continued). 

PORK,  PICKLED,  SALTED,  AND 

SMOKED  (Continued). 

1 

Bacon,  smoked,  lean- 

Per  ct. 

Perct. 

Perct. 

Perct. 

Perct. 

Per  ct. 

Per  ct. 

Cats. 

Edible  portion ....... 

2 

31.8 

15.5 

14.6 

42.6 

11.0 

2085 

As  purchased 

2 

17.0 

26.5 

13.0 

12.3 

35.5 

8.7 

1740 

Bacon,  smoked,  medium  fat- 

Edible  portion     ..... 

17 

18,8 

9.9 

9.4 

67.4 

4.4 

3030 

As  purchased 

17 

'7.7 

17.4 

9.1 

8.6 

62.2 

4.1 

2795 

Ribs,  cooked,  as  purchased  . 

1 

33.6 

24.8 

26.6 

37.6 

2.2 

2050 

Steak,  cooked,  as  purchased  . 

1 

33.2 

19.9 

45.4 

1.5 

2285 

PORK, CANNED 

Brawn,  boars"  brains,  as  pur- 

chased .  .                          . 

2 

49.0 

25.2 

23.4 

23.0 

46 

1440 

Boars'  heads,  as  purchased   . 

2 

55.3 

20.7 

19.2 

22.2 

3.3 

1320 

Ham,  deviled,  as  purchased  . 

6 

44.1 

19.0 

18.5 

34.1 

3.3 

1790 

SAUSAGE. 

Aries- 

Edible  portion 

17.2 

26.8 

24.9 

50.6 

7.3 

2635 

.\s  purchased 

5.2 

16.3 

25.4 

23.6 

48.0 

6.9 

2495 

Banquet- 

Edible  portion .   .   .  ■    ... 

62.7 

18.3 

17.9 

15.7 

3.7 

1005 

As  purchased 

1.6 

61.7 

18.0 

17.7 

15.4 

3.6 

985 

Bologna- 

Edible  portion 

60.0 

18.7 

18.4 

17.6 

0.3 

3.7 

1095 

As  purchased 

'3.3 

55.2 

18.2 

18.0 

19.7 

3.8 

1170 

Farmer- 

Edible  portion 

23.2 

29.0 

27.2 

42  0 

7.6 

2310 

As  purchased 

'3.9 

22.2 

27.9 

2G.2 

40.4 

7.3 

2225 

Frankfort,  as  purchased 

57.2 

19.6 

19.7 

18.6 

l.i 

3.4 

1170 

Holsteiner— 

Edible  portion 

25.6 

29.4 

29.4 

.37.3 

3.4 

4.3 

2220 

As  purchased 

'2.'2 

25.1 

28.7 

28.7 

36.5 

3.3 

4.2 

2135 

Lyons,  pure  ham- 

Edible  portion 

.32.5 

32.3 

32.3 

27.2 

8.0 

1750 

As  purchased 

io.'o 

29.2 

29.1 

29.1 

24.5 

7.2 

1575 

Pork,  as  purchased    .... 

11 

39.8 

13.0 

12.7 

44.2 

"l.i 

2.2 

2125 

Pork  sausage  meat,  as  pur- 

chased      

.46.2 

17.4 

17.9 

32.5 

3.4 

1695 

Pork  and  beef  chopped  to- 

gether, as  purchased    .   . 

55.4 

19.4 

19.5 

24.1 

1.0 

1380 

Salmi- 

Edible  portion 

2 

30.5 

24.1 

22.6 

39.9 

7.0 

2130 

As  purchased       

2 

'9.3 

27.6 

21.8 

20.5 

36.2 

6.4 

1935 

Summer- 

Edible  portion 

3 

23.2 

26.0 

24.6 

44.5 

7.7 

2360 

As  purchased 

2 

'7.0 

20.9 

24.5 

23.0 

42.1 

7.0 

2230 

Tongue,  as  purchased     .   .   . 

1 

46.4 

20.1 

17.3 

33.1 

3.2 

1770 

Wienerwurst,  as  purchased  . 

1 

43.9 

28.0 

22.1 

1.6 

4.4 

1485 

SAUSAGE,  CANNED. 

Beef,  as  purchased 

1 

59.6 

17.9 

17.8 

20.6 

2.0 

1200 

Bologna,  Italian,  as  purch'd 

1 

42.6 

24.9 

23.2 

27.S 

6.4 

1635 

Frankfort,  as  purchased     .   . 

1 

72.7 

14.9 

14.6 

9.9 

2.8 

695 

Oxford,  as  purchased  .... 

1 

28.9 

9.9 

9.9 

58.5 

0.6 

2.1 

2665 

Pork- 

Edible  portion 

1 

56.6 

16.6 

16.6 

24.8 

2.0 

1355 

As  purchased 

1 

12.6 

49.5 

14.5 

14.5 

21.6 

1.8 

1180 

POULTRY  AND  GAME,  FRESH. 

Chicken,  broilers- 

Edible  portion     

3 

74.8 

21.5 

21.6 

2.5 

1.1 

505 

As  purchased 

3 

51.6 

43.7 

12.8 

12.6 

1.4 

0.7 

295 

Fowls- 

Edible  portion 

26 

63.7 

19.S 

19.0 

16.3 

1.0 

1045 

As  purchased 

26 

25.9 

47.1 

13.7 

14.0 

12.3 

0.7 

775 

CHEMICAL  COMPOSITION  OF  AMERICAN  FOOD  MATERIALS        819 


Food  materials. 


Animal  Food  (Continued). 

POULTRY   AND  GAME,  FKESH 
(Coutiimcd). 

Goose,  young- 
Edible  portion 

As  purchased 

"Turkey— 

Edible  portion 

As  purchased 

Chicken  gizzard,  as  purch'd 
Chicken  heart,  as  purchased 
Chicken  liver,  as  purchased 

Goose  gizzard 

Goose  liver,  as  purchased  .  . 
Turkey  gizza'-d,  as  purchased 
Turkey  heart,  as  purchased 
Turkey  liver,  as  purchased  . 

POULTRY  AND  GAME,  COOKED. 

Capon — 

Edible  portion 

As  purchased 

Capon,  with  stuflBng — 

Edible  portion 

As  purchased 

Chicken,    fricasseed,    edible 

portion 

Turkey,  roast,  edible  portion 

Turkey,  roast,  light  and  dark 

meat,  and  stuffing,  edible 

portion    ....      .  .  .  . 

POULTRY  AND  GAME,  CANNED. 

Chicken  sandwich,  as   pur- 
chased   

Turkey  sandwich,  as  purch'd 
Plover,  roast,  as  purchased  . 
Quail,  as  purchased 

FISH,  FRESH. 

Alewife,  whole — 

Edible  portion 

As  purchased 

Bass,  black,  whole — 

Edible  portion 

As  purchased 

Bass,  red,  whole- 
Edible  portion 

As  purchased       

Bass,  sea,  whole — 

Edible  portion 

As  purchased 

Bass,  striped,  whole- 
Edible  portion 

As  purchased 

Bass,   striped,    entrails     re- 
moved, as  purchased  .   . 

Blackflsh,  whole- 
Edible  portion 

As  purchased 

Blackflsh,  entrails  removed, 
as  purchased 

Bluefish,  entrails  removed- 
Edible  portion 

As  purchased 

Buffalo  fish,  entrails  rem'd— 

Edible  portion 

Ab  purchased 


^ 

1 

O  ai 

a 

u  ■« 

aS 

^ 

305 

Q> 

S5 

rt 

Per  ct. 

1 

1 

17 

6 

3 

3 

22 

7 

1 

1 
1 
1 

1 

1 
1 

1 
1 

io.4 

1 

1 

7.7 

1 

1 

1 

1 

1 

1 

., 

- 

49.5 

- 

54.8 

1 

1 

63.5 

1 

1 

56.1 

6 

0 

55.0 

1 

51.2 

4 

•2 

60.2 

2 

55.7 

1 
1 

48.6 

1 

1 

52 

5  1 

Protein. 


Per  ct.lPer  ct. 


46.7 
38.5 

55.5 
42.4 

72.5 
72.0 
69.3 
73.8 
62.6 
62.7 
68.6 
69.6 


59.9 
53.6 


62.1 
57.2 


67.."> 
52.0 


10.3 
13.4 


74.4 
37.6 


76.7 
34.6 


81.6 
29.8 


79.3 
34.8 


77.7 
35.1 


79.1 
31.4 


78.5 
40.3 


78.6 
37.3 


Per  ct. 

16.3 
13.4 


21.1 

16.1 

24.7 

20.7 

22.4 

19!6  I    19.4 

16.6 

20.5 

16.8 

22.9 


27.0 
24.2 


21.8 
20.1 


46.9  1  20.8 
47.4  ;  20.7 
22.4 
66.9      21.8 


19.4 
9.8 


20.6 
9.3 


16.9 
6.2 


18.0 
8.4 


18.7 
7.4 


19.4 
10.0 


18.0 
8.5 


20.6 
15.7 
24.7 
21.1 


27.3 
24.5 


28.4 
17.1 


19.2 
9.7 


20.4 
9.3 


16.7 
6.1 


18.8 
8.3 


18.3 
8.3 


19.0 
9.8 


17.9 
8.5 


Per  ct. 

36.2 
29.8 

22.9 
18.4 
1.4 
5.5 
4.2 
5.8 
15.9 
14.5 
13.2 
5.2 


11.5 
10.3 


10.9 
10.3 


11.5 

18.4 


20.5  I  30.0 
20.7  i  29.2 
10.2 


2.8 
1.1 


5^ 


3.7 
1.2 


0.6 


3.8 
3.5 


5.5 


7.6 
1.7 


Perct. 

0.8 
0.7 


CaU. 

1830 
1505 


2.6 
2.7 
2.1 
1.6 


1.5 
0.8 


1.2 
0.5 


1.2 
0.4 


1.4 

0.6 


1.2 
0.5 


1.1 
0.4 


1.3 
0.7 


1.2 
0.6 


1.0 

1360 

0.8 

1075 

1.4 

520 

1.4 

615 

1.7 

640 

1.0 

610 

1.2 

1050 

1.1 

1015 

1.0 

870 

1.7 

655 

1.3 

986 

1.2 

885 

1.4 

935 

1.2 

875 

1.0 

855 

1.2 

1295 

1655 
1615 

985 
775 


570 
285 


455 
206 


335 
125 


390 

170 


465 
200 


405 
165 


175 


410 
210 


430 
205 


CHEMICAL  COMPOSITIOX  OF  AMERICAy  FOOD  MATERIALS 


Food  materials. 


Animal  Food  (Continued). 
FISH,  FRESH  {Continued). 

Butter-fish,  whole- 
Edible  portion 

As  purchased       

Catfish- 
Edible  portion 

As  purchased       ..'.... 

Ciscoe,  whole,  edible  portion 

Ciscoe,  entrails  removed,  as 
purchased 

Cod,  whole- 
Edible  portion 

As  purchased    . 

Cod,  dressed,  as  purchased  . 

Cod,  sections,  edible  portion 

Cod,  steaks- 
Edible  portion 

As  purchased 

Cusk,  entrails  removed — 

Edible  portion 

As  purchased       

Eels,  salt  water,  head,  skin, 
and  entrails  removed- 
Edible  portion 

As  purchased 

Flounder,  whole — 

Edible  portion 

As  purchased 

Flounder,  entrails  removed, 
as  purchased 

Haddock,  entrails  removed- 
Edible  portion  

As  purchased 

Hake,  entrails  removed — 

Edible  portion 

As  purchased 

Halibut,  steaks  or  sections- 
Edible  portion 

As  purchased 

Herring,  whole — 

Edible  portion 

As  purchased 

Kiiigfish,  whole — 

Edible  portion 

As  purchased 

Lamprey,  whole- 
Edible  portion  

As  purchased 

Mackerel,  whole — 

Edible  portion 

As  purchased       

Mackerel,  entrails  removed, 
as  purchased 

Mullet.  whole- 
Edible  portion 

As  purchased 

Muskellunge,  whole — 

Edible  portion . 

As  purchased 

Perch,  white,  whole- 
Edible  portion 

As  purchased 

Perch,  yellow,  whole,  edible 
portion 

Pickerel,  pike,  whole- 
Edible  portion 

As  purchased 


Protein. 


Perct. 


52.5 
29.9 


61.5 
57.0 

51.0 

52.5 

17.7 

42.6 

56.6 

45.8 

44.7 
40.7 

57.9 

49.2 

62.5 

47.1 


Perct. 

70.0 
40.1 


64.1 

51.7 
74.0 

65.6 

82.6 
38.7 
58.5 

82.5 

79.7 
72.4 

82.0 
49.0 


71.6 
57.2 


84.2 
32.6 


35.8 


81.7 
40.0 


83.1 
39.5 


75.4 
61.9 


72.5 
41.7 


79.2 
34.4 


71.1 
38.5 


73.4 
40.4 


74.9 
31.5 


76.3 
38.7 


75.7 
28.4 


79.3 


79.8 
42.2 


Perct. 

18.0 
10.3 

14.4 
11.6 
18.5 


&  ■ 


16.5 
8.4 
11.1 
16.7 

18.7 
17.0 

17.0 
10.1 


18.6 
14.8 


14.2 
5.4 


17.2 

8.4 


15.4 

7.3 


18.6 
15.3 


19.5 
11.2 


18.9 

8.2 


15.0 
8.1 


18.7 
10.2 


19.5 

8.2 


20.2 
10.2 


19.3 
7.3 


18.7 


18.7 
9.9 


17.8 
10.2 

14.4 
11.6 
18.1 


16.3  I    15.9 


15.8 
8.0 
10.6 
16.3 

18.6 
16.9 

16.9 
10.1 


18.3 
14.6 


13.9 
5.1 


6.3 


16.8 
8.2 


15.2 


18.4 
15.1 


18.9 
10.9 


18.7 
8.1 


14.9 
8.1 


18.3 
10.0 


19.3 

8.1 


19.6 
10.0 


19.1 

7.2 


18.6 
9.9 


Per  ct. 

11.0 
6.3 

20.6 
16.6 
6.8 

7.5 

0.4 
0.2 
0.2 
0.3 

0.5 
0.5 

0.2 
0.1 


0.3 


13.3 
7.2 


Per  ct. 


Per  ct. 

1.2 
0.6 

0.9 
0.7 
1.1 

0.9 

1.2 

0.6 
0.8 
0.9 

1.2 
1.0 

0.9 
0.5 


1.0 
0.8 


1.3 
0.5 


0.6 


1.2 
0.6 


1.0 

0.5 


1.0 
0.9 


1.5 
0.9 


1.2 
0.5 


0.7 
0.4 


1.2 
0.7 


0.7 


1.2 
0.5 


1.6 
0.8 


1.2 
0.4 


1.2 


1.1 
0.6 


CHEMICAL  COMPOSITION  OF  AMERICAN  FOOD  MATERIALS        821 


Food  materials. 


as 


Protein. 


-0(3 

pq 


•O 

a>a 

35 

1^ 

J3 

■^s. 

< 

(>< 

Animal  Food  {Continued) 
FISH,  FKESH  (Continued). 

Pike,  gray,  whole- 
Edible  fiortion 

As  purchased 

Pollock,  dressed— 

Edible  portion 

As  purchased 

Pompano,  whole- 
Edible  portiou 

As  purchased 

Porgy,  whole — 

Edible  portion 

As  purchased 

Kcd  grouper,  entrails  rem'd- 

Edible  portion 

As  purchased 

Ked  snapper,  whole — 

Edible  portion 

As  purchased 

Salmon,  whole — 

Edible  portion 

As  purchased 

Salmon,  entrails  removed,  as 
purchased 

Salmon,  landlocked,  whole, 
spent- 
Edible  portion 

As  purchased 

Salmon,  California,  anterior 
sections- 
Edible  portion 

As  purchased 

Shad,  whole  — 

Edible  portion 

As  purchased 

Shad  roe,  as  purchased  .   .   . 

Sheepshead,  whole- 
Edible  portion  

As  purchased 

Skate,  lobe  of  body- 
Edible  portion 

As  purchased 

Smelt,  whole- 
Edible  portion 

As  purchased 

Spanish  mackerel,  whole- 
Edible  portion 

As  purchased 

Sturgeon,  anterior  sections- 
Edible  portion 

As  purchased 

Tomcod,  whole — 

Edible  portion 

As  purchased 

Trout,  brook,  whole — 

Edible  portion 

As  purchased 

Trout,  salmon  or  lake — 

Edible  portion 

As  purchased 

Turbot— 

Edible  portion 

As  purchased 

Weakfish,  whole — 

Edible  portion 

As  purchased 


Perct. 
63, 

28 

45 

60 

55 

46 

34. 
29, 


59, 


51.9 


Per  cl. 


76.0 
54.3 


72.8 
39.5 


75.0 
29.9 


79.5 
35.0 


78.5 
42.0 


64.6 
40.9 


48.1 


77.7 
42.3 


63.6 
57.9 

70.6 
35.2 
71.2 

75.6 
26.9 

82.2 
40.2 

79.2 
46.1 

68.1 
44.5 

78.7 
67.4 

81.5 
32.7 

77.8 
40.4 

70.8 
36.6 

71.4 
37.3 

79.0 
38.0 


Per  ct. 

17.9 
6.6 

21.6 
15.4 

18.8 
10.3 

18.6 
7.4 

19.3 
8.5 

19.7 
10.8 

22.0 
15.3 

13.8 


17.8 
9.7 


17.8 
16.7 

18.8 

9.4 

20.9 

20.1 
6.6 

18.2 
8.9 

17.6 
10.1 

21.5 
14.1 

18.1 
15.1 

17.2 
6.9 

19.2 
9.9 

17.8 
9.1 

14.8 

7.7 

17.8 
8.6 


Per  ct. 

17.3 
6.4 

21.7 
15.5 

18.7 
10.2 

18.5 
7.4 

18.8 
8.4 

19.2 
10.6 

21.2 
14.4 

13.5 


17.8 
9.8 


17.5 
16.1 


18.6 
9.2 


19.5 
6.4 


15.3 

7.5 


17.3 
10.0 


21.0 
13.7 


18.0 
15.4 


17.1 

6.8 


18.9 
9.8 


17.7 
9.2 


12.9 
6.8 


17.4 
8.4 


Perct. 

0.8 
0.3 

0.8 
0.6 

7.5 
4.3 

5.1 
2.1 

0.6 
0.2 

1.0 
0.6 

12.8 
8.9 

8.1 


17.8 
14.8 

9.5 

4.8 
3.8 

3.7 
0.2 

1.4 

0.7 

1.8 
1.0 

9.4 
6.2 

1.9 
1.6 

0.4 

0.2 

2.1 
1.1 

10.3 
5.1 

14.4 

7.5 

2.4 
1.1 


Per  ct. 


Per  ct 

l.I 
0.4 


1.0 
0.5 


1.4 

0.0 


1.1 
0.5 


1.3 
0.7 


1.4 
0.9 


0.8 


12 
0.6 


1.1 
0.9 

1.3 
0.7 
1.5 

1.2 
0.5 

1.1 

0.6 

1.7 
1.0 

1.5 
1.0 

1.4 
1.2 

1.0 
0.4 

1.2 

0.6 

1.2 

0.6 

1.3 
0.7 

1.2 
0.6 


OaU. 

365 
135 

435 
310 

665 
375 

560 
225 

385 
165 

410 
225 

950 
660 

600 


470 
255 


1080 
935 

7,W 
380 
600 

530 
130 

400 
195 

405 
230 

795 
525 

415 
350 

335 
135 

445 
230 

765 
385 

885 
460 

430 
205 


822        CHEMICAL  COMPOiilTION  OF  AMERICAN  FOOD  MATERIALS 


Food  materials. 


as 


Protein. 


Animal  Food  {Continiied). 

FISH,  FRESH  (Continued). 

Whitefish,  whole- 
Edible  portion 

As  purchased 

FISH,  COOKED. 

Bluefish,  cooked,  edible  por- 
tion     

Spanish  mackerel,  broiled- 
Edible  portion 

As  purchased 

FISH,  PRESERVED  AND  CANNED 

Cod,  salt- 
Edible  portion  

As  purchased 

Cod,  salt,  "  boneless  " — 

Edible  portion 

As  purchased 

Haddock,  smoked — 

Edible  portion     

As  purchased 

Haddock,  smoked,  cooked, 
canned,  as  purchased  .  . 
Halibut,  smoked — 

Edible  portion 

As  purchased 

Herring,  smoked — 

Edible  portion 

As  purchased       

Lamprey,  canned — 

Edible  portion 

As  purchased 

Mackerel,  salt,  entrails  re- 
moved- 
Edible  portion 

As  purchased 

Mackerel,    salt,    canned,   as 

purchased 

Mackerel,  salt,  canned  in  oil — 

Edible  portion 

As  purchased 

Mackerel,  salt,  dressed — 

Edible  portion 

As  purchased 

Minogy,  pickled,  canned — 

Edible  portion 

As  purchased 

Pilchard  in  tomatoes,  canned, 
Russia,  as  purchased  .  . 
Salmon,  canned — 

Edible  portion 

As  purchased 

Sardines,  canned- 
Edible  portion . 

As  purchased 

Sturgeon,  dried,  Russia — 

Edible  portion 

As  purchased 

Sturgeon,  caviare,  pressed, 
Russia,  as  purchased  ,  . 
Trout,  brook- 
Edible  portion  .   .      •    ... 

As  purchased  .... 

Tunney.as  purchased    .   .  . 


24.9 
1.6 
;2.2 

7.0 
44.4 
18.2 

22.9 

31.5 
19.7 
18.7 

4.2 
5.0 


Per  ct. 

69.8 
32.5 


68.2 


68.9 
63.5 


53.5 
40.2 


55.0 
54.8 


72.5 
49.2 


49.4 
46.0 


.34.6 
19.2 


63.3 
51.7 


42.2 
32.5 


58.3 
39.9 


43.4 

34.8 


56.5 
46.0 


52.7 


63.5 
56.8 


.■52.3 
53.6 


50.6 
44.1 


I    68.4 
3.5  I   66.1 

i   72.7 


Per  ct. 

22.9 
10.6 


25.9 


23.7 
21.8 


25.4 
19.0 


27.3 

27.7 


23.3 
15.8 


20.7 
19.3 


36.9 
20.5 


16.9 
13.8 


21.1 
16.3 


25.4 
17.4 

17.3 
13.9 

22.0 
17.9 

27.9 

21.8 
19.5 

23.0 
23.7 

31.8 

27.8 

30.0 

22.3 
21.5 
21.7 


Per  ct 

22a 
10.3 


23.2 
21.4 


21.5 
16.0 


25.7 
28.6 


23.7 
16.1 


21.8 


20.6 
19.1 


36.4 

20.2 


22.0 
17.0 


23.5 
16.1 


17.3 
13.9 


21.9 

17.8 


21.8 
19.5 


22.4 
24.0 


32.2 
28.1 


22.S 
20.9 
21.5 


4.5 


0.3 
0.3 


0.2 
0.1 


15.0 
14.0 


15.8 


12.2 
10.0 


22.6 
17.4 


14.1 

9.7 

26.4 
21.2 

18.6 
15.1 

15.8 

12.1 

7.5 

19.7 
12.1 

9.6 
8.4 

19.7 

6.1 
59 
4.1 


Per  Ct. 


Per  ct. 

1.6 
0.7 


24.7 
18.5 


19.0 
14.7 


3.6 
2.4 


15.0 
13.9 


1.3.2 
7.4 


4.0 
3.3 


18.2 
10.2 


3.2 

4.1 


12.9 
10.4 


3.0 
2.4 


4.0 


2.6 

2.0 


5.6 
5.3 


7.6 
6.7 


3.7 
3.6 
1.7 


670 
6S0 
575 


CHEMICAL  CO.MI'OSITIOX  OF  .1  J/A'A'/r.LV  FOOD  MlTEIflM.S       823 


Food  materials. 


Animal  Food  {Continued). 

AMPHIBIA. 

Frogs^^iegs— 

Edible  portion 

As  purchased 


SHELLFISH,  ETC.,  FRESH. 

Clams,  long,  in  shell- 
Edible  portion 

As  purchased 

Clams,  round,  in  shell — 

Edible  portion 

As  purt'hased 

Clams,  round,  removed  from 
shell,  as  purchased    .   .   . 

Crabs,  hardshell,  whole — 

Edible  portion 

As  purchased 

Crayfish,  abdomen,  whole- 
Edible  portion 

As  purchased 

Lobster,  whole^ 

Edible  portion 

As  purchased 

Mussels,  in  shell — 

Edible  portion 

As  purchased 

Oysters,  in  shell- 
Edible  portion 

As  purchased 

Oysters,  solids,  as  purchased 

Scallops,  as  purchased    .   .    . 

Terrapin- 
Edible  portion 

As  purchased 

Turtle,  green,  whole — 

Edible  portion 

As  purchased    


SHELLFISH,  ETC.,  CANNED. 

Clams,  long,  as  purchased 
Clams,  round,  as  purchased 
Crabs,  as  purchased  .... 
Lobster,  as  purchased  .  .  . 
Oysters,  as  purchased  .  .  . 
Shrimp,  as  purchased  .  .   . 


3  at 


EGGS. 

Hens',  uncooked— 1 

Edible  portion 

As  purchased 

Hen's,  boiled- 
Edible  portion 

As  purchased 

Hens',  boiled  whites,  edible 
portion        

Hens',  boiled   yolks,  edible 
portion 


60 
19 

11     I 

I 
11     I 


Per  ct. 
32.0 

41.9 
67.5 

52.4 
86.6 
(il.V 
46.'7 
81.4 

■75.4 
76.0 


11.2 
11.2 


Per  cl. 

83.7 
56.9 


85.8 
49.9 


28.0 

80.8 

77  1 
36.7 

81.2 
10.9 

79.2 
30.7 

84.2 
44.9 

86.9 
16.1 

88.3 
80.3 

74.5 
18.3 

79.8 
19.2 


84.5 
82.9 
80.0 
77.8 
83.4 
70.8 


73.7 
65.5 


73.2 
65.0 


86.2 
49.5 


Protein. 


Per  ct. 

15.5 
10.5 


8.6 
5.0 


16.6 
7.U 

16.0 
2.1 

16.4 
5.9 

8.7 
4.6 

6.2 

1.2 
6.0 
14.8 

21.2 
5.2 

19.8 

4.7 


9.0 

10.5 
l.'l.S 
18.1 
8.8 
25.4 


13.4 
11.9 


13.2 
11.7 


12.3 

15.7 


Per  ct, 

15.1 
10.3 


14.8 
13.1 


14.0 
12.4 


13.0 
16.1 


Perct.  Per  ct. 

0.2  i    .■  . 
0.1  1    .    . 


1.0 
0.6 


0.4 
0.1 


2.0 
0.9 

0.5 
0.1 

1.8 
0.7 

1.1 
0.6 

1.2 
0.2 
1.3 
0.1 

3.5 
0.9 

0..5 
0.1 


10.5 
9.3 


12.0 
10.7 


0.2 
33.3 


2.0 
1.1 


4.2 
1.4 


1.2 
0.6 

1.0 

0.1 

0.4 
0.2 

4.1 
2.2 

3.7 
0.7 
3.3 
3.4 


2.9 
3.0 
0.7 
0.5 
3.9 
0.2 


*  a. 


Perct:,  Cols. 


1.5 

0.7 


2.6 
1.5 


2.7 
0.9 


1.9 
1.0 

2.0 
0.4 
1.1 
1.4 

1.0 
0.2 

1.2 
0.3 


2.3 
2.8 
2.0 
2.5 
1.5 
2.6 


1.0 
0.9 


0.8 
0.7 


0.6 
l.l 


295 
200 


240 
140 

215 
70 

340 

415 
195 

340 
45 

390 
140 

285 
150 

235 

45 

230 

345 

545 
135 

390 
90 


275 
285 
370 
390 
335 
520 


720 
635 


765 
680 


250 
1705 


1  Eggs  are  difficult  of  analysis  and  the  discrepancy  between  the  protein  by  factor 
and  bv  difference  maybe  due  in  part  to  incomplete  determination  of  nitrogen  and  fat. 
It  is  also  probable  that  the  factor  6.25  is  not  correct  for  eggs.  The  value  of  protein  by 
difference  is  perhaps  the  more  nearly  correct,  and  has  been  used  in  the  computatioa 
Of  the  fuel-value  per  pound. 


824        CHEMICAL  COMPOSITION  OF  AMERICAN  FOOD  MATERIALS 


Food  materials. 


S  c 


Protein. 


to  ci 
tt<o 


Eh 


Animal  Food  (Continued). 

DAIRY  PRODUCTS,  ETC. 

Butter,  as  purchased    .... 

Buttermilk,  as  purchased  .  . 

Cheese,  American  pale,  as 
purchased 

Cheese,  American  red,  as  pur- 
chased   

Cheese,  Boudon,  aspurchased 

Cheese,  California  nat,  as  pur- 
chased   

Cheese,  Cheddar,  as  purcb'd 

Cheese,  Cheshire,  as  purch'd 

Cheese,  cottage,  as  purchased 

Cheese,  Crown  brand  cream, 
as  purchased       .... 

Cheese,  Dutch,  as  purchased 

Cheese,  Fromage  de  Brie,  as 
purchased 

Cheese,  full  cream, as  purch'd 

Cheese,  imitation  full  cream, 
Ohio,  as  purchased  . 

Cheese,  imitation  old  English, 
as  purchased 

Cheese,  Limburger,  as  pur- 
chased   

Cheese,  Neuchalel,  as  pur- 
chased   

Cheese,  partly  skimmedmilk, 
as  purchased 

Cheese,  pineapple,  as  purch  d 

Cheese,  Roquefort,  as  jjurch'd 

Cheese,  skimmed  milk,  as 
purchased 

Cheese,  Swiss,  as  purchased  . 

Cheese,  whole  milk.  (See 
Full  cream  cheese.)    - 

Cream,  as  purchased    .... 

Kumiss,  as  purchased     .   .   . 

Milk,  condensed,  sweetened, 
as  purchased 

Milk,  condensed,  unsweet- 
ened, "evaporated 
cream,"  as  purchased  .   . 

Milk,  skimmed,  as  purchased 

Milk,  whole,  as  purchased   . 

Whey,  as  purchased 

MISCELLANEOUS. 

Gelatin,  as  purchased  .... 

Call's  foot  jelly,  as  purchased 

Isinglass,  sturgeon,  as  pur- 
chased   

Spinal  column,  sturgeon,  as 
purchased 

Lard,  refined,  as  purchased  . 

Lard,  unrefined,  as  purch'd  . 

Tallow,  refined,  as  purch'd   . 

Cottolene,  as  purchased  .   .   . 

Oleomargarine,  as  purchased 

Beef  juice,  as  purchased     .   . 


Perct. 


Perct. 

11.0 
910 


28.6 
55.2 

34.0 
27.4 
37.1 
72.0 

31.4 
35.2 

60.2 
34.2 

37.9 

20.7 

42.1 

50.0 

38.2 
23.0 
39.3 

45.7 
31.4 


74.0 
89.3 


26.9 


68.2 
90.5 
87.0 
93.0 


13.6 
77.6 

19.0 

17.7 

'4.8 


9.5 
93.0 


Per  ci. 

1.0 
3.0 

28.8 


16.4 

24.3 
27.7 
26.9 
20.9 

5.2 


15.9 
•25.9 


30.1 

23.0 

18.7 

25.4 
29.9 
22.6 

31.5 
27.6 


9.6 
3.4 
3.3 
1.0 


91.4 
4.3 

89.3 

59.8 

2.2 


1.2 
4.9 


Per  ct 


37.1 


25.9 


84.2 
77.4 

1.1 


Per  ct. 

85.0 
0.5 

35.9 

38.3 
20.8 

33.4 

36.8 

30.7 

1.0 

58.0 
17.7 

21.0 
33.7 

31.7 

42.7 

29.4 

27.4 

29.5 
.S8.9 
29.5 

16.4 
34.9 


IS.,") 
2.1 


9.3 
0.3 
4.0 
0.3 


0.1 


1.6 

17.1 
100.0 

94.0 
100.0 
100.0 

83.0 
0.6 


Perct. 

4.8 
0.3 


4.5 
4.1 
0.9 
4.3 


1.4 
2.4 


1.3 

0.4 

1.5 

3.6 
2.6 
1.8 

22 
1.3 


4.5 
5.4 


11.2 
5.1 
5.0 
5.0 


0.8 


Perct 

3.0 

0.7 


3.5 
7.0 

3.8 
4.0 
4.4 
1.8 

3.2 
10.0 

1.5 
3.8 

4.5 

5.2 

5.1 

2.4 

3.3 

5.6 
6.8 

4.2 

4.8 


0.5 
0.4 


1.7 

0.7 
0.7 
0.7 


2.1 
0.7 


6.3 
1.5 


CHEMICAL  C0MP08IT10\  OF  AMERICAN  FOOD  MATERIALS       825 


v. 

hi 

Food  iiiaierials. 

O  to 
t-,  <0     1 

c 

s 

"3  73 

a  <s        0- 

I 

e8       1  oJ5  o 

J3 

>  a 

^      1    « 

^ 

h 

;^ 

H 

£ 

< 

b 

Vegetable  Food. 

FLOURS.  MEALS,  ETC. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct. 

Per  ct 

Per  ct. 

Cats. 

Barley,  granulated 

1 

^ 

10.9 

7..') 

0.9 

798 

0.7 

0.9 

1660 

Barley  meal  and  flour  .... 

3 

11,9 

10.,^ 

2.2 

72.8 

6.5 

•  2.6 

1640 

Barley,  pearled 

3 

11.5 

8.5 

1.1 

77.8 

0.3 

1.1 

16.50 

Buckwheat  flour 

17 

13.6 

6.4 

1.2 

77.9 

0.4 

0.9 

1620 

Buckwheat  preparations- 

Farina  and  groats 

2 

10.9 

4.1 

0.4 

84.1 

0.2 

0.5 

1660 

Self-raising 

14 

11.6 

8.2 

1.2 

73,4 

0.4 

5.6 

1570 

Corn  flour 

3 

12.6 

7.1 

1.3 

78.4 

0.9 

0,6 

1645 

Corn  meal,  graniilar.   .  .   . 

19 

12.5 

9.2 

1.9 

75.4 

1.0 

1.0 

1655 

Corn  meal,  unbolted — 

Edible  portion 

7 

11.6 

8.4 

4.7 

74.0 

1.3 

1730 

As  purchased 

7 

io.9 

10.3 

7.5 

4,2 

65,9 

1.2 

1545 

Pop  corn 

2 

4.3 

10.7 

5.0 

78.7 

1.4 

1.3 

1875 

Corn  preparations— 

Ceraline      

5 
17 

10.3 
11.8 

9.6 
8.3 

1.1 
0.6 

78.3 
79.0 

0.4 
0.9 

0.7 
0.3 

1680 

Hominy 

1650 

Hominy,  cooked 

1 

79.3 

2.2 

0.2 

17.8 

0.5 

380 

Parched 

2 

5.2 

11.5 

8.4 

72.3 

2,6 

1915 

Kafir  corn 

1 
16 

16.8 
7.3 

6.6 
16.1 

3.8 
7.2 

70,6 
67,5 

"i.i 

0.9 

2.2 
1,9 

1.595 

Oatmeal 

1860 

Oatmeal,  boiled 

1 

84.5 

2.8 

0.5 

11,5 

0.7 

285 

Oatmeal  gruel 

2 

91.6 

1.2 

0.4 

6.3 

0.5 

155 

Oatmeal  water 

2 

96,0 

0.7 

0.1 

2.9 

0.3 

70 

Oats,  other  preparations — 

Rolled  oats 

20 

7.7 

16.7 

7.3 

66.2 

1.3 

2.1 

1850 

Miscellaneous 

26 

7.9 

16.3 

7.3 

66.8 

0.9 

1.7 

1855 

All  analyses,  average  .   .  . 

46 

7.8 

16.5 

7,3 

66.5 

1.0 

1.9 

1850 

Rice 

21 

12,3 

8.0 

0.3 

79.0 

0,2 

0.4 

1630 

Rice,  boiled 

3 

72.5 

2.8 

0.1   i    24.4 

0.2 

525 

Rice,  flaked 

2 

9.5 

7.9 

0.4  ]    81.9 

0.2 

0.3 

1685 

Rice  flour 

4 

8 

■    ' 

8.5 
12.9 

8,6 
6.8 

6,1    '     68  0 

16.1 
0.4 

8,8 
0,7 

1680 

Rye  flour 

0.9 

78.7 

1630 

Rye  meal 

1 

11.4 

13.6 

2.0 

71.5 

1.8 

1.5 

1665 

Wheat  flour,  California  fine  . 

3 

13.8  1      7.9 

1.4 

76.4 

0.5 

1625 

Wheat  flour,  entire  wheat  .   . 

9 

11.4  i    13,8 

1.9 

71.9 

0.9 

1,0 

1675 

Wheat  flour,  gluten 

5 

12.0       14.2 

1.8 

71.1 

0.6 

0,9 

1665 

Wheat  flour,  Graham   .... 

13 

11.3       13.3 

2.2 

71.4 

1.9 

1.8 

1670 

Wheat  flour,  prepared  (self- 

raising)    

29 

10.8      10.2 

1.2 

73.0 

0,4 

4,8 

1600 

Wheat   flour,    patent    roller 

process,  bakers'  grade  .   . 

14 

11.9      13.3 

1.5 

72.7 

0.7 

0.6 

1665 

Wheat   flour,   patent    roller 

process,       family      and 

straight  grade- 

Spring  wheat 

3 

11.9 

10.9 

1.1 

75.6 

0.1 

0.5 

1655 

Winter  wheat 

6 

13.1 

12.3 

1.1 

73.0 

0.3 

0.5 

1635 

Undesignated 

19 

12.9 

10.4 

1.0 

75.2 

0.1 

0.5 

1635 

All  analyses,  average  .   .   . 

28 

12.8 

10.8 

1.1 

74.8 

0.2 

0.5 

1640 

Wheat   flour,    patent    roller 

process,  grade  not  indi- 

cated      

111 

11.5 

11.4 

1.0 

75.6 

0.2 

0.5 

1660 

Wheat   flour,    patent    roller 

process,  high  grade — 

Spring  wheat 

Winter  wheat 

23 

12,3 

11.7 

1.1 

74.& 

0.1 

0.4 

16.')0 

6 

13.3 

11.0 

0.9 

74.4 

0.3 

0.4 

1625 

Undesignated 

28 

12.5 

10.8 

1.0 

75.2 

0.1 

0.5 

1640 

All  analyses,  average  .   .   . 

57 

12.4 

11.2 

1.0 

74.9 

0.2 

0.5 

1645 

Average  of  all  analyses  of 

high  and  medium  grades 

210 

12.0 

11.4 

1.0 

75.1 

0.3 

0.5 

1650 

Wheat   flour,   patent    roller 

process,  low  grade .      .   . 

13 

12.0 

14.0 

1.9 

71.2 

0.8 

0.9 

1665 

Wheat  flour,  unclass.  process. 

grade  not  indicated- 

Spring  wheat 

4 

12,4 

10.5 

1.0 

75.4 

0.5 

0.7 

1640 

826        CHEMICAL  COMPOSITION  OF  AMERICAX  FOOD  MATERIALS 


o.st 

01 

03  O)  tuo 

4) 

9 

Food  materials. 

L.    CO 

cj 

"■S.S 

"S-d 

£  a 

01 

'3 

"S 

OJ5  V 

J2 

J3 

>  a 

-A 

tf 

Oh 

fe 

^ 

£ 

< 

b. 

Vegetable  Food  (Continued). 

FLOURS,  MEALS,  ETC.  {Cont'd). 

Wheat  flour,  etc.  (Continued)— 

Per  at. 

Per  ct. 

Perci. 

Per  ct. 

Perct. 

Per  ct. 

Per  ct. 

Cats. 

Winter  wheat 

21 

11.9 

10.7 

1.0 

75.8 

0.4 

0.6 

1650 

Undesignated 

8 

9.4 

10.4 

1.2 

78.4 

0.9 

0.6 

1700 

All  analyses,  average  .   .   . 

33 

11.4 

10.6 

1.1 

76.3 

0.2 

0.6 

1665 

Wheat   preparations,  break- 

fast foods- 

Cracked  and  crushed  .   .   . 

11 

10.1 

11.1 

1.7 

75.5 

1.7 

1.6 

1685 

Farina         

9 
7 

10 
3 

22 

10.9 
8.7 

1U.4 
8.9 
9.4 

11.0 
tl3.4 
10.5 
13.6 
13.1 

1.4 
1.4 
2.0 
1.7 
2.1 

76.3 
74.3 
76.0 
74.6 
74.1 

0.4 
1.8 
0.9 
1.3 
0.9 

0.4 
2.2 
1.1 
1.2 
1.3 

1685 

Flaked 

1690 

Germs 

1695 

Glutens 

1715 

Miscellaneous 

1710 

Parched  and  toasted    .  .   . 

6 

8.6 

13.6 

2.4 

74.5 

0.8 

0.9 

1740 

Shredded    

6 

8.1 

10.5 

1.4 

77.9 

1.7 

2.1 

1700 

All  analyses,  average  .   .   . 

74 

9.6 

12.1 

1.8 

75.2 

1.0 

1.3 

1700 

Wheat  preparations- 

Macaroni       

11 

10.3 

13.4 

0.9 

74.1 

1.3 

1665 

Macaroni,  cooked 

1 

78.4 

3.0 

1.5 

15.8 

1.3 

415 

Noodles 

2 

10.7 

11.7 

1.0 

75.6 

0.4 

1.0 

1665 

Spaghetti 

3 
15 

10.6 
11.0 

12.1 
10.9 

0.4 
2.0 

76.3 
72.0 

0.4 

0.6 
4.1 

1660 

Vermicelli 

1625 

BREAD,  CRACKERS,  PASTRY, 

ETC. 

Bread,  brown,  as  purchased  . 

2 

43.6 

5.4 

1.8 

47.1 

2.1 

1050 

Bread,  cassava,  as  purchased 

1 

10.6 

9.1 

0.3 

79.0 

1.1 

1650 

Bread,  corn  (johnnycake),  as 

purchased      

5 

38.9 

7.9 

4.7 

46.3 

2.2 

1205 

Bread,  rye,  as  purchased    .   . 

21 

35.7 

9.0 

0.6 

53.2 

0.5 

1.5 

1180 

Bread,  rye,  black,  as  purch'd 

1 

36.9 

9.6 

0.6 

48.9 

4.0 

1115 

Bread,  rye,  whole,  as  purch'd 

2 

50.7 

11.9 

0.6 

35.9 

1.2 

0.9 

915 

Bread,  rye  and  wheat,  as  pur- 

chased   

1 

35.3 

11.9 

0.3 

51.5 

1.0 

1190 

Bread,  wheat — 

Buns,  as  purchased  .... 

1 

29.0 

6.3 

6.5 

57.3 

0.4 

0.9 

1455 

Buns,  cinnamon,  as  purch'd 

1 

23.6 

9.4 

7.2 

59.1 

0.7 

1575 

Buns,  currant,  as  purch'd  . 

1 

27.5 

6.7 

7.6 

57.6 

i.i 

0.6 

1515 

Buns,  hot  cross,  as  purch'd 

1 

36.7 

79 

4.8 

49.7 

0.9 

1275 

Buns,  sugar,  as  purchased 

3 

29.6 

8.1 

6.9 

54.2 

0.3 

1.2 

1450 

Gluten  bread,  as  purchased 

6 

38.2 

9.3 

-1.4 

49.8 

1.3 

1160 

Graham  bread,  as  purch'd 

27 

35.7 

8.9 

1.8 

52.1 

I.i 

1.5 

1210 

Biscuit,  homemade,  as  pur- 

chased   

3 

32.9 

8.7 

2.6 

.55.3 

0.7 

0.5 

1300 

Biscuit,  Maryland,  as  pur- 

chased   

2 

24.6 

8.4 

5.6 

60.1 

1.3 

1.3 

1510 

Biscuit,  soda,  as  purchased 

1 

22.9 

9.3 

13.7 

52.6 

1.5 

1730 

Rolls.  French,  as  purchased 

2 

32.0 

8.5 

2.5 

55.7 

0.6 

1.3 

1300 

Rolls,  plain,  as  purchased 

.5 

25.2 

9.7 

4.2 

.59.9 

0.3 

1.0 

1470 

Rolls,  Vienna,  as  purch'd  . 

1 

31.7 

8.5 

2.2 

56.5 

0.4 

1.1 

1300 

Rolls,  water,  as  purchased 

2 

32.6 

9.0 

3.0 

54.2 

1.2 

1300 

Rolls,  all  analyses,  as  pur- 

chased   

20 

29.2 

8.9 

4.1 

56.7 

0.6 

1.1 

1395 

Rolls,  large,  cheap,  as  pur- 

chased   

1 

29.4 

9.4 

0.8 

59.4 

1.0 

1315 

Toasted  bread,  as  purch'd  . 

5 

24.0 

11.5 

1.6 

61.2 

1.7 

1420 

White    bread,    biscuit,    as 

purchased 

3 

35.2 

8.0 

1.4 

54.3 

0.3 

1.1 

1220 

Wh  i  te  bread ,  butter,  as  pur- 

chased   

1 

32.2 

7.9 

1.1 

57.7 

0.4 

1.1 

1265 

WTiite  bread,  cheap  grade, 

as  purchased 

6 

33.2 

10.9 

1.3 

53.6 

1.0 

1255 

White  bread,  cream,  as  pur- 

chased   

6 

33.2  1 

9.8 

0.9 

55.0 

0.2 

1.1 

1245 

White    hroad,   homemade. 

as  purchased  ' 

38 

35.0 

9.1  ■ 

1.6  ' 

53.3 

0.2 

1.0 

1226 

CHEMICAL  COMI'OHITION  OF  AMERICAX  FOOD  MATElilALU       827 


Food  materials. 


Vegetable  Food  {Continued). 

BKEAD,  CRACKERS,  PASTRY, 

ETC.  {Continued). 
Bread,  wheat  {Continued) — 
White  bread,  milk,  as  pur- 
chased   

White    bread,   miscellane- 
ous, as  purchased  .... 
White  bread.  New  England, 

as  purchased 

White    bread,    Quaker,   as 

purchased 

White  bread,  split,  as  pur- 
chased   

White   bread,    Vienna,   as 

purchased 

White  bread,  all  analyses, 
as  purchased,  average  .   . 
Whole  wheat  bread,  as  pur- 
chased   

Zwieback,  as  purchased  .   . 
Crackers- 
Boston  (split)  crackers,  as 

purchased 

Butter  crackers,  as  purch'd 
Cream  crackers,  as  purch'd 
Egg  crackers,  as  purchased 
Flatbread,  as  purchased 
Graham  crackers,  as  pur 

chased 

Miscellaneous,  as  purch'd 
Oatmeal  crackers,  as  pur- 
chased   

Oyster  crackers,  as  purch'd 
Pilot  bread,  as  purchased 
Pretzels,  as  purchased  .  . 
Saltines,  as  purchased  .  . 
Soda  crackers,  as  purch'd 
Water  crackers,  as  purch'd 
All  analyses,  as  purchased, 

average    

Cracker  meal,  as  purchased 
Cake — 
Baker's  cake,  as  purchased 
Chocolate    layer    cake,   as 

purchased 

Coffee  cake,  as  purchased  . 
Cup  cake,  as  purchased  .  . 
Drop  cake,  as  purchased  . 
Frosted  cake,  as  purchased 


11 1-> 

2; 


103 

7 

4 

3 

25 

198 

12 
4 


Per  cl 


V 

Pi 

i 

.a 
SI 

.a 
< 

Per  cl. 

Per  ct. 

Per  cl. 

Perct. 

Perct. 

Perct. 

36.5 

9.6 

1.4 

51.1 

1.4 

35.(5 

9.3 

1.2 

52.7 

0.5 

1.2 

36.0 

9.1 

1.2 

52.1 

1.0 

35.8 

8.3 

1.1 

53.7 

0.3 

1.1 

34.6 

9.3 

1.0 

54.1 

0.2 

1.0 

34.2 

9.4 

1.2 

54.1 

0.5 

1.1 

35.3 

9.2 

1.3 

53.1 

0.5 

1.1 

38.4 

9.7 

0.9 

49.7 

1.2 

1.3 

5.8 

9.8 

9.9 

73.5 

1.0 

7.5 

11.0 

8.5 

71.1 

0.8 

1.9 

7.2 

9.6 

10.1 

71.6 

0.4 

1.5 

6.8 

9.7 

12.1 

69.7 

4.6 

1.7 

5.8 

12.6 

14.0 

66.6 

0.4 

1.0 

9.8 

14.9 

0.5 

73.6 

1.2 

5.4 

10.0 

9.4 

73.8 

1.5 

1.4 

7.1 

10.2 

8.8 

72.4 

0.4 

1.5 

6.3 

11.8 

11.1 

69.0 

1.9 

1.8 

4.8 

11.3 

10.5 

70.5 

0.2 

2.9 

8.7 

11.1 

5.0 

74.2 

0.3 

1.0 

9.6 

9.7 

3.9 

72.8 

0.5 

4.0 

5.6 

10.6 

12.7 

68.5 

0.5 

2.6 

5.9 

9.8 

9.1 

73.1 

0.3 

2.1 

6.4 

11.7 

5.0 

75.7 

0.4 

1.2 

6.8 

10.7 

8.8 

71.9 

0.5 

1.8 

9.2 

10.9 

6.0 

72.9 

0.2 

1.0 

31.4 

6.3 

4.6 

56.9 

0.8 

20.5 

6.2 

8.1 

64.1 

1.1 

21.3 

7.1 

7.5 

63.2 

0.4 

0.9 

15.6         5.9 

9.0 

68.5 

0.3 

1.0 

16.6         7.6 

14.7 

60.3 

0.1 

0.8 

18.2 

5.9 

9.0 

64.8 

2.1 

V 

3 

>  a 
^  3 

3  o. 


Cats. 
1190 

1205 

1190 

1200 

1220 

1230 

1215 

1140 

1970 


1885 
1935 
1990 
2060 
1665 

1955 
1905 

1970 
1965 
1800 
1700 
2005 
1925 
1835 

1905 
1810 

1370 

1650 
1625 
1765 
1885 
1695 


d 

■6 

li 

2 

tl 

"£.3 

.0 

.c 

Ph 

fM 

0 

f^ 

< 

fe 

Percl. 

Per  ct. 

Percl. 

Per  cl. 

Per  ct. 

Per  ct. 

Cals. 

White  bread  from  high-grade  patent  flour 

32.9 

8.7 

1.4 

56.5 

0.5 

1270 

White  bread  from  regular  patent  flour  .   . 

84.1 

9.0 

1.3 

54  9 

0.7 

1245 

White  bread  from  baker's  flour 

39.1 

10.6 

1.2 

48.3 

0.9 

1145 

White  bread  from  low-grade  flour    .... 

40.7 

12.6 

1.1 

'44.3 

1.3 

1105 

828        CHEMICAL  COMPOaiTIOy  OF  AMERICAX  FOOD  MATERIALS 


,    ,  ^ 

b 

'*.» 

C  S  t.  .' 

%. 

O  aa 

^  M«=: 

<U 

Ol 

rt  oj  he 

3 

Food  materials. 

11 

1 

Ol 

c 
'3 

2 

■3 

"2| 

3 

A 

^ 

tf 

^ 

Ph 

fe 

^ 

M 

< 

p^ 

Vegetable  Food  (Continued). 

BREAD,  CKACKERS,  PASTRY, 

ETC.  {Continued). 

Fer  ct. 

Per  ct. 

Perct. 

Per  ct. 

Per  ct.  Per 

ct.  Perct. 

Cals. 

Cake  (Continued)— 

Fruit  cake,  as  purchased   . 

4 

17.3 

5.9 

10.9 

64.1 

1.8 

1760 

Giugerbread,  as  purchased 

2 

18.8 

5.8 

9.0 

63.5 

O.J 

»         2.9 

1670 

Miscellaneous,  as  purch'd  . 

4 

21.9 

5.9 

10.6 

60.1 

1.5 

1675 

Sponge  cake,  as  purchased 

3 

15.3 

6.3 

10.7 

65.9 

1.8 

1795 

All  analyses,  except  fruit, 

as  purchased,  average  .  . 

27 

19.9 

6.3 

9.0 

63.3 

0.^ 

I        1.5 

1675 

Cookies,  cakes,  etc.— 

Molasses  cookies,  as   pur- 

chased        ... 

6 

6.2 

7.2 

8.7 

75.7 

2.2 

1910 

Miscellaneous   cookies,  as 

purchased 

5 

10.3 

6.7 

9.6 

72.4 

1. 

>        1.0 

1875 

Sugar  cookies,  as  purchased 

9 

8.3 

7.0 

10.2 

73.2 

1. 

1.3 

1920 

All  analyses,  as  purchased. 

average 

20 

8.1 

7.0 

9.7 

73.7 

0. 

)        1.5 

1910 

Fig  biscuits  or  bars,  as  pur- 

chased   

1 

17.9 

4.6 

6.6 

69.8 

1. 

1        1.1 

1660 

Ginger  snaps,  as  purchased 

7 

6.3 

6.5 

8.6 

76.0 

0. 

J        2.6 

1895 

Lady  Angers,  as  purchased 

3 

15.0 

8.8 

5.0 

70.6 

0. 

I        0.6 

1685 

Macaroons,  as  purchased   . 

4     1    .    . 

12.3 

6.5 

15.2 

65.2 

1. 

1        0.8 

1975 

Wafers,  miscellaneous,  as 

purchased 

5 

6.6 

8.7 

8.6 

74.5 

0. 

1        1.6 

1910 

Wafers,  vanilla,  as  purch'd 

6 

6.7 

6.6 

14.0 

71.6 

0. 

}        1.1 

2045 

Wafers,  all  analyses,  as  pur- 

chased, average  

11 

6.6 

7.6 

11.6 

72.9 

0. 

i        1.3 

1985 

Miscellaneous     cakes,    as 

purchased 

17 

8.2 

7.4 

9.0 

74.0  ! 

0. 

^      1.2 

1900 

Doughnuts,  as  purchased  .   . 

9 

18.3 

6.7 

21.0 

53.1 

0. 

7      0.9 

2000 

Jumbles,  as  purchased  .   .   . 

4 

14.3 

7.4 

13.5 

63.7 

0., 

5      1.1 

1890 

Pie,  apple,  as  purchased    .   . 

4 

42.5 

3.1 

9.8 

42.8 

1.8 

1270 

Pie,  cream,  as  purchased   .   . 

3 

32.0 

4.4 

11.4 

51.2 

1.0 

1515 

Pie,  custard,  as  purchased    . 

1 

62.4 

4.2 

6.3 

26.1 

1.0 

830 

Pie,  lemon,  as  piirchased  .   . 

1 

47.4 

3.6 

10.1 

37.4 

1.5 

1190 

Pie,  mince,  as  purchased  .   . 

3 

41.3 

5.8 

12.3 

38.1 

2.5 

1335 

Pie,  raisin,  as  purchased    .   . 

1 

37.0 

3.0 

11.3 

47.2 

1.5 

1410 

Pie,  squa.sh,  as  purchased  .   . 

1 

64.2 

4.4 

8.4 

21.7 

1.3 

840 

Pudding,     Indian-meal,     as 

purchased 

1 

60.7 

5.5 

4.8 

27.5 

1.5 

815 

Average  Composition 

0/  Some  Common  Candies. 

<4H       • 

II 

Z 

Water. 

6 
g 

1 

a  " 

4 
< 

Insoluble  in  cold           Remarks, 
water. 

Perct. 

Percl. 

Per  ct. 

Per  ct. 

Per  cent. 

Broken  candv  .  . 

8 

4.6 

75.3 

14.0 

2.7 

0.9  in  one  sample 

Cream  candy  .   . 

20 

5.3 

77.1 

8.7 

0.1 

0.2  in  one  sample 

Marshmallows    . 

3 

5.6 

33.3 

24.1 

1.1 

27.0 

One  sample  con- 
tained 44.8  per 
cent,  insoluble 
matter  (starch 
and  flour). 

Caramels  .... 

3 

3.3 

37.5 

15.2 

1.4 

32.2 

One  sample  con- 
tained 66.3  per 
cent,  insoluble 
matter  (starch 
and  flour). 

Chocolate  creams 

1 

3.8 

58.3 

13.8 

0.5 

IhA 

CHEMICAL  COMl'OtilTlOS  OF  AMEIUVAS  FOOD  .\L\TFl{L\.LH        829 


Food  materials. 


pur- 


Vegetable  ^ood  (Cmitinued) 

BREAD,  CRACKERS,  PASTRY, 

ETC.  (Continued). 

Pudding,  rice  custard,  as  pur- 
chased   

Pudding,   tapioca,   as 
chased 

Pudding,  tapioca,  with  ap- 
ples, as  purchased  ... 

SUGARS,  STARCHES,  ETC. 

Candy,  as  purchased  .... 
Honey,  as  purchased  .... 
Molasses,  caue,  as  purchased 
Starch,  arrowroot,  as  purch'd 
Starch,  cornstarch,  as  purch'd 
Starch,  manioca,  as  purch'd 
Starch,  sago,  as  purchased  . 
Starch,  tapioca,  as  purchased 
Sugar,  cotree  or  brown  sugar, 

as  purchased 

Sugar,  granulated,  as  pur- 
chased   

Sugar,  maple,  as  purchased  . 
Sugar,  powdered,  as  purch'd 
Syrup,  maple,  as  purchased  . 

VEGETABLES.* 

Artichokes,  as  purchased  .  . 
Asparagus,  fresh,  as  purch'd 
Asparagus,  cooked,  as  pur- 
chased   

Beans,  butter,  green — 

Edible  portion 

As  purchased 

Beans,  dried,  as  purchased  . 
Beans,  frijoles  (New  Mexico), 

as  purchased        

Beans,  Lima,  dried,  as  pur- 
chased   

Beans,  Lima,  fresh- 
Edible  portion 

As  purchased 

Beans,  mesquite,  dry,  as  pur- 
chased   

Beans,  string,  cooked,  edible 

portion 

Beans,  string,  fresh — 

Edible  portion 

As  purchased 

Beets,  cooked,  edible  portion 
Beets,  fresh — 

Edible  portion 

As  purchased 

Cabbage — 

Edible  portion 

As  purchased 

Cabbage,  curly,  as  purchased 
Cabbage,  sprouts — 

Edible  portion 

As  purchased 


17 

15 

1 

1 
1 

7 

328 


Per  ct. 


61.8 


Per  ct. 
59.4 

64.5 

70.1 


18.2 

25.1 

2.3 

io.'s 

12.2 
11.4 


79.5 
94.0 

91.6 

58.9 
29.4 
12.6 

7.5 

10.4 

68.5 
30.8 

4.8 

95.3 

89.2 
83.0 
88.6 

87.5 
70.0 

91.5 

7.7 
87.3 


Per  ct. 
4.0 

3.3 

0.3 


9.4 
4.7 
22.5 

21.9 

18.1 

7.1 
3.2 

12.2 

0.8 

2.3 
2.1 
2.3 

1.6 
1.3 

1.6 
1.4 

4.]   I 

4.7  I 

1.8  I 


O  S  b 


Perct. 
4.6 

3.2 

0.1 


0.1 
0.4 
0.1 


0.2 
0.2 

3.3 

0.6 
0.3 

1.8 

1.3 

1.5 

0.7 
0.3 

2.5 

1.1 

0.3 
0.3 
0.1 

0.1 
0.1 

0.3 
0.2 
0.6 

1.1 
0.4 


Per  ct. 
31.4 

28.2 

29.3 


96.0 
81.2 
69.3 
97.5 
90.0 
88.8 
78.1 
88.0 

95.0 

100.0 
82.8 

100.0 
71.4 


16.7 
3.3 


29.1 
14.6 
59.6 

65.1 

65.9 

22.0 
9.9 

77.1 

1.9 

7.4 
6.9 
7.4 

9.7 

7.7 

5.6 
4.8 
6.2 

4.3 
1.7 


Pei-  ct.  Per  ct. 
0.6 

0.8 

0.2 


0.2 
3.2 
0.2 

0.1 
0.3 
0.1 


1.7 
0.8 


1.9 

1.8 


0.9 
1.1 


1.0 
0.7 


2.0 
1.0 
3.5 

4.2 

4.1 

1.7 
0.8 

3.4 

0.9 

0.8 
0.7 
1.6 

1.1 
0.9 

1.0 
0.9 

1.8 

1.7 

0.6 


ri    3 


Cats. 
825 

720 

575 


1785 
1520 
1290 
181.^ 
1675 
1665 
1635 
1650 

1765 

1860 
1540 
1860 
1330 


365 
105 


740 
370 
1605 

1675 

1625 

570 
255 

1765 

95 

195 
180 
185 

215 
170 

145 

125 
215 

215 
80 


1  Such  vegetables  as  potatoes,  squash,  beets,  etc.,  have  a  certain  amount  of  inedible 
material,  skin,  seeds,  etc.  The  amount  varies  with  the  method  of  preparing  the  vege- 
tables, and  can  not  be  accurately  estimated.  The  figures  given  for  refuse  of  vege- 
tables, fruits,  etc.,  are  assumed  to  represent  approximately  the  amount  of  refuse  ia 
these  foods  as  ordinarily  prepared. 


830 


CHEMICAL  COMPOSITION  OF  AMERICAN  FOOD  MATERIALS 


Food  materials. 


Vegetable  Food  (Continued). 
VEGETABLES  ( Continued). 

Carrots,  fresh — 

Edible  portion 

As  purchased 

Carrots,    evaporated,  edible 
portion     ...  .... 

Cauliflower,  as  purchased  .   . 

Celery- 
Edible  portion 

As  purchased 

CoUards— 

Edible  portion 

As  purchased 

Corn,  green- 
Edible  portion  

As  purchased 

Cucumbers- 
Edible  portion 

As  purchased 

Eggplant,  edible  portion    .   . 

Greens,  beet,  cooked,  as  pur- 
chased   

Greens,  dandelion,  as  purch'd 

Greens,  turnip-salad,  as  pur- 
chased   

Kohl-rabi,  edible  portion  .  . 

Leeks- 
Edible  portion 

As  purchased       

Lentils,  dried,  as  purchased  . 

Lettuce — 

Edible  portion 

As  purchased 

Mushrooms,  as  purchased .   . 

Okra— 

Edible  portion 

As  purchased 

Onions,  fresh — 

Edible  portion 

As  purchased 

Onions,  cooked,  prepared,  as 
purchased 

Onions,  green  (New  Mexico) — 

Edible  portion 

As  purchased 

Parsnips- 
Edible  portion 

As  purchased 

Peas,  dried,  as  purchased  .  . 

Peas,  green- 
Edible  portion 

As  purchased 

Peas,  green,  cooked,  as  pur- 
chased   

Peas,    sugar,    green,    edible  ; 
portion t 

Cowpeas,  dried,  as  purchased 

Cowpeas,  green,  edible  port'n 

Potatoes,  raw  or  fresh—  1 

Edible  portion 

As  purchased j 

Potatoes,  evaporated,  as  pur- 
chased   

Pototoes,  cooked,  boiled,  as 
purchased 


Perct 
20.0 


Per  ct. 

88.2 
70.6 

3.5 
92.3 

94.5 
75.6 

87.1 
39.5 

75.4 
29.4 

95.4 
81.1 
92.9 

89.5 
81.4 

86.7 
91.1 

91.8 

78.0 
8.4 

94.7 
80.5 
88.1 

90.2 
78.9 

87.6 
78.9 

91.2 

87.1 
42.6 

83.0 
66.4 
9.5 

74.6 

40.8 


81.8 
13.0 
65.9 

78.3 
62.6 

7.1 

75.5 


Per  ct. 

1.1 
0.9 

7.7 
1.8 

1.1 
0.9 

4.5 
1.5 

3.1 
1.2 

0.8 
0.7 
1.2 

2.2 
2.4 

4.2 
2.0 

1.2 
1.0 

25.7 

1.2 
1.0 
3.5 

1.6 

1.4 

l.fi 
1.4 


1.0 
0.5 

1.6 

1.3 

24.6 

7.0 
3.6 

6.7 

3.4 
21.4 
9.4 

2.2 
1.8 

8.5 

2.5 


in 


Per  ct 

0.4 
0.2 

3.6 
0.5 

0.1 
0.1 

0.6 

0.2 

1.1 

0.4 

0.2 
0.2 
0.3 

3.4 
1.0 

0.6 
0.1 

0.5 
0.4 
1.0 

0.3 
02 
0.4 

0.2 
0.2 

0.3 
0.3 

1.8 

0.1 
O.l 

0.5 
0.4 
1.0 

0.5 
0.2 

3.4 

0.4 
1.4 
0.6 

0.1 
0.1 

0.4 

0.1 


Perct. 

9.3 
7.4 

80.3 
4.7 

3.3 
2.6 

6.3 

2.9 

19.7 

7.7 

3.1 
2.6 
5.1 

3.2 
10.6 

6.3 
5.5 

5.8 

5.0 

59.2 

2.9 
2.5 
6.8 

7.4 
6.5 

9.9 
8.9 

4.9 

11.2 
5.5 

13.5 

10.8 
62.0 

16.9 

9.8 


13.7 
60.8 
22.7 

18.4 
14.7 

80,9 

20.9 


Perct. 
1.1 


0.5 

0.7 
0.8 


1.2 

0.6 

0.7 
0.8 
3.4 


2.5 
4.5 
1.7 


1.6 
4.1 


Per  ct. 

1.0 
0.9 

4.9 
0.7 

1.0 
0.8 


1.5 
0.6 

0.7 
0.3 

0.5 
0.4 
0.5 

1.7 
4.6 

2.2 
1.3 

0.7 
0.6 
5.7 

0.9 

0.8 
1.2 

0.6 
0.5 

0.6 
0.5 


0.6 
0.3 

1.4 
1.1 
2.9 

1.0 
0.6 


0.7 
3.4 
1.4 

1.0 

0.8 

3.1 

1.0 


CHEMICAL  COMPOSITIOy  OF  AilERICAX  FOOD  MATERIALS       831 


Food  materials. 


li-r^: 


•=•3^ 


^  3 


ChZ*. 
2675 


570 
4b0 

925 

120 
60 

135 
95 

105 
65 

190 

las 

125 

no 

260 

215 

105 

105 

1740 

185 
125 


110 
85 

600 
95 
90 
SO 


320 

240 
360 
480 
95 
455 

225 

no 

85 

130 
255 
820 
150 
235 
465 
106 


Vegetable  Food  {Continued). 
VEGETABLES  (Continued). 

Potatoes,  cooked,  chips,   as 
purchased 

Potatoes,    cooked,     mashed 
and  creamed,  as  purch'd 

Potatoes,     sweet,     raw,     or 
fresh- 
Edible  portion 

As  purchased 

Potatoes,  sweet,  cooked  and 
prepared,  as  purchased  . 

Pumpkins- 
Edible  portion 

As  purchased 

Kadishes — 

Edible  portion 

As  purchased 

Rhubarb — 

Edible  portion 

As  purchased 

Ruta-bagas— 

Edible  portion 

As  purchased 

Sauerkraut,  as  purchased  .   . 

Spinach,  fresh,  as  purchased 

Spinach,  cooked,  as  purch'd 

Squash- 
Edible  portion 

As  purchased 

Tomatoes,  fresh,  as  purch'd  . 

Tomatoes,  dried,  as  purch'd  . 

Turnips — 

Edible  portion 

As  purchased 


VEGETABLES,  CANNED. 

Artichokes,  as  purchased  .  . 
Asparagus,  as  purchased  .  . 
Beans,  baked,  as  purchased  . 
Beans,  string,  as  purchased  . 
Beans,  little  green,  as  purch'd 
Beans,  wax,  as  purchased  .  . 
Beans,  haricots  verts,  as  pur- 
chased   

Beans,  haricots  flageolets,  as 

purchased 

Beans,  haricots  panaches,  as 

purchased 

Beans,  lima,  as  purchased  . 
Beans,  red  kidney,  as  purch'd 
Brussels  sprouts*  as  purch'd 
Corn,  green,  as  purchased 
Corn  and  tomatoes,  as  pur 

chased 

Macedoine    (mixed    vegeta- 
bles), as  purchased    .  . 
Okra,  as  purchased   .   .   . 
Okra  and  tomatoes,  as  pur- 
chased   

Peas,  green,  as  purchased 
Potatoes,  sweet,  as  purchased 
Pumpkins,  as  purchased 
Squash,  as  purchased  .   . 
Succotash,  as  purchased 
Tomatoes,  as  purchased  . 


2 
7 
5 
12 
19 


Per  ct. 


Per  ct. 
2.2 


69.0 
55.2 


93.1 
46.5 


91.8 
64.3 


94.4 
56.6 


88.9 
62.2 


88.3 
44.2 
94.3 
7.3 

89.6 
62.7 


92.5 
94.4 
68.9 
93.7 
93.8 
94.6 

95.2 

81.6 

86.1 
79.5 
72.7 
93.7 
76.1 

87.6 

93.1 
94.4 

91.8 
85.3 
.■15.2 
91.6 
87.6 
75.9 
94.0 


Perct.  Perct. 
6.8      39.8 


2.6 


1.8 
1.4 

3.0 

1.0 
0.5 

1.3 
0.9 

0.6 
0.4 

1.3 
0.9 

1.7 
2.1 
2.1 

1.4 

0.7 
0.9 
12.9 

1.3 
0.9 


1.4 

0.7 

1.1 
3.6 
1.9 
0.8 
0.9 
3.6 
1.2 


3.0 


0.7 
0.6 

2.1 

0.1 
0.1 

0.1 
0.1 

0.7 
0.4 

0.2 
0.1 
0.5 
0.3 
4.1 

0.5 
0.2 
0.4 
8.1 

0.2 
0.1 


0.1 
2.5 
0.1 
0.1 
0.1 


0.3 
0.2 
0.1 
1.2 


0.3 
0.2 
0.4 
0.2 
0.5 
1.0 
0.2 


Per  ct.  Per  ct. 

46.' 


27.4 
21.9 


42.1 


6.0 
3.8 
3.2 
2.6 

9.0 

4.5 

3.9 

62.3 

8.1 

5.7 


•5.0 
2.8 

19.6 
3.8 
3.4 
3.1 

2.5 

12.5 

9.2 
14.6 
18.5 

3.4 
19.0 

9.6 

4.5 
3.6 

5.2 

9.8 
41.4 

6.7 
10.5 
18.6 

4.0 


1.2 

0.7 

1.1 

1.2 

0.9 

0.8 
0.6 


0.6 
0.5 
2.5 
0..5 
0.6 
0.6 


1.0 
1.2 
1.2 
0.5 
0.8 

0.5 

0.6 
0.7 

0.5 
1.2 
0.8 
1.1 
0.7 
0.9 
0.5 


Perct. 

4.5 


1.1 

0.9 


o.r, 

0.3 

1.0 
0.7 

0.7 
0.4 

1.1 
0.8 
5.2 
2.1 
1.4 

0.8 
04 
0.5 
9.4 

0.8 
0.6 


1.7 
1.2 
2.1 
1.3 
1.5 
1.2 


1.0 
1.6 
1.6 
1.3 
0.9 

0.8 

1.0 
1.2 

1.6 
1.1 
1.1 
0.7 
0.5 
0.9 
0.6 


832        CHEMICAL  COMPOSITIOX  OF  AMERICAN  FOOD  MATERIALS 


Food  materials. 


Vegetable  Food  (Continued). 

PICKLES,  CONDIMENTS,  ETC. 

Catsup,  tomato,  as  purchased 
Horse-radish,  as  purchased  . 
Horse-radish,  evaporated,  as 

purchased 

Olives,  green — 

Edible  portion 

As  purchased 

Olives,  ripe — 

Edible  portion 

As  purchased 

Peppers  (paprica),  green, 
dried,  as  purchased  .  .  . 
Peppers,  red  chili,  as  purch'd 
Pickles,  cucumber,  as  pur- 
chased   

Pickles,  mixed,  as  purchased 
Pickles,  spiced,  as  purchased 

FRUITS,  BEKKIES,ETC.,FRESH.l 

Apples— 

Edible  portion 

As  purchased 

Apricots- 
Edible  portion 

As  purchased 

Bananas,  yellow — 

Edible  portion 

As  purchased 

Blackberries,  as  purchased  . 
Cherries — 

Edible  portion 

As  purchased 

Cranberries,  as  purchased  .   . 
Currants,  as  purchased  . 
Figs,  fresh,  as  purchased,  av- 
erage  

Grapes- 
Edible  portion 

As  purchased    

Huckleberries,  edible  portion 
Lemons — 

Edible  portion 

As  purchased 

Lemon-juice 

Muskmelons — 

Edible  portion 

As  purchased 

Nectarines — 

Edible  portion 

As  purchased 

Oranges — 

Ediole  portion 

As  purchased   ....... 

Peaches — 

Edible  portion 

As  purchased 


So 


Per  ct 


27.0 
19.0 


25.0 

'e.o 

35.0 
'5.0 

25.0 
30.0 


50.0 

6.6 

27.0 

18.0 


Per  ct.  Per  et. 


82.8 
86.4 

4.3 

58.0 
42.3 

64.7 
52.4 

5.0 
5.3 

92.9 
93.8 
77.1 


84.6 
63.3 

85.0 
70.9 

75.3 
48.9 
86.3 

80.9 
76.8 
88.9 
85.0 

79.1 

77.4 
58.0 
81.9 

89.3 
62.5 


89.5 
44.8 


82.9 
77.4 


86.9 
63.4 


89.4 
73.3 


1.1 
0.8 

1.7 
1.4 

15.5 
9.4 

0.5 
1.1 
0.4 


0.4 
0.3 

1.1 
1.0 

1.3 

0.8 
1.3 

1.0 
0.9 
0.4 
1.5 


1.3 
1.0 

0.6 

1.0 
0.7 


0.6 
0.3 


0.6 
0.6 


0.8 
0.6 


Per  cl. 

0.2 
0.2 

0.8 

27.6 
20.2 

25.9 
21.0 

8.5 

7.7 

0.3 
0.4 
0.1 


0.6 
0.4 
1.0 

0.8 
0.8 
0.6 


1.6 

1.2 
0.6 

0.7 
0.5 


0.2 
0.1 


0.1 
0.1 


Per  ct. 

12.3 
10.5 

77.7 

11.6 
8.5 

4.3 
3.5 

63.0 
70.0 

2.7 
4.0 
20.7 


14.2 
10.8 

13.4 
12.6 

22.0 
14.3 
10.9 

16.7 
15.9 
9.9 
12.8 

18.8 

19.2 
14.4 
16.6 

8.5 
5.9 
9.8 

9.3 
4.6 

15.9 
14.8 

11.6 
8.5 

9.4 

7.7 


Per  ct. 


3.6 


Per  ct. 

3.2 
1.5 


1.7 
1.2 

3.4 

2.7 

8.0 
7.6j 

3.6 

(1.7 
1.7 


0.3 
U.3 

0.5 
0.5 

0.8 
0.6 
0.5 

06 
fi.6 
0.2 
0.7 

0.6 

0.5 
0.4 
U.3 

0.5 
0.4 


0.6 
0.3 


0.6 
0.6 


0.5 
0.4 


0.4 
0.3 


1  Fruits  contain  a  certain  proportion  of  inedible  materials,  as  skin,  seeds,  etc., 
which  are  properly  classed  as  refuse.  In  some  fruits,  as  oranges  and  prunes,  the 
amount  rejected  ineating  is  practically  the  same  as  the  refuse.  In  others,  as  apples 
and  pears,  more  or  less  of  the  edible  material  is  ordinarily  rejected  vc ith  the  skin  and 
seeds  and  other  inedible  portions.  The  edible  material  which  is  thus  thrown  away, 
and  should  properly  be  classed  with  the  waste,  is  here  classed  with  the  refuse.  The 
figures  for  refuse  here  given  represent,  as  nearly  as  can  be  ascertained,  the  quantitiea 
ordinarily  rejected. 


CHEMICAL  COMPOSITIOS    OF  AMERICAX  FOOD  MATERIALS        833 


Food  materials. 


Vegetable- Food  (Continued). 

FRUITS,  BERRIES,  ETC.,  FRESH 

(VoiUinued). 

Pears- 
Edible  portion  

As  purchased 

Persimmons,  edible  portion  . 

Pineapple,  edible  i)ortion  .  . 

Plums — 

Edible  portion 

As  purchased 

Pomegranates,  edible  iKirtion 

Prunes — 

Edible  portion 

As  purchased 

Raspberries,  red,  as  pureh'd 

Easpberries,     black,    edible 
portion 

Raspberry  juice,  edible  por- 
tion     

Strawberries— 

Edible  portion 

As  purchased       

Watermelons- 
Edible  portion 

As  purchased 

Whortleberries,  as  purchased 

FRUITS,  ETC.,  DRIED. 

Apples,  as  purchased   .... 

Apricots,  as  purchased    .   .   . 

Citron,  as  purchased  .... 

Currants,  Zante,  as  pureh'd  . 

Dates- 
Edible  portion     ...... 

As  purchased 

Figs,  as  purchased 

Grapes,  ground,  as  purchased 

Pears,  as  purchased 

Prunes- 
Edible  portion 

As  purchased 

Raisins — 

Edible  portion 

As  purchased 

Raspberries,  as  purchased     . 

FRUITS,  ETC.,  canned;   AND 
JELLIES,  PRESERVES,  ETC. 

Apples,  crab,  as  purchased    ; 

Apple  sauce,  as  purchased    . 

Apricots,  as  purchased    .   .   . 

Apricot  sauce,  as  purchased 

Blackberries,  as  purchased  . 

Blueberries,  as  purchased  .  . 

Cherries,  as  purchased    .  .  . 

Cherry  jelly— 

1st  quality  as  purchased 
2d  quality,  as  purchased 

Figs,  stewed,  as  purchased    . 

Grape  butter,  as  purchased  . 

Marmalade  (orange  peel),  as 
purchased 

Peaches,  as  purchased    .  .   . 

Pears,  as  purchased 

Pineapples,  as  purchased  .   . 

Prune  sauce,  as  purchased    . 
53 


a  a! 


Percl. 

io'.o 


Per  cl. 

SiA 
7G.0 
66.1 
89.3 

78.4 
74.5 
76.8 

79.6 
75.6 
85.8 

84.1 

49.3 

90.4 
85.9 

92.4 
37.5 
82.4 


28.1 
29.4 
19.0 
17.2 

15.4 
13.8 
18.8 
34.8 
16.5 

22.3 
19.0 

14.6 
13.1 
8.1 


42.4 
61.1 

81.4 
45.2 
40.0 
85.6 

77.2 

21.0 

38.4 
56.5 
36.7 

14.5 
88.1 
81.1 
61.g 
76.6 


Perot. 

0.6 
0.5 
0.8 
0.4 

1.0 
0.9 
1.5 

0.9 
0.7 
1.0 

1.7 

0.5 

1.0 
0.9 

0.4 
0.2 
0.7 


1.6 

4.7 
0.5 
2.4 

2.1 
1.9 
4.3 

2.8 
2.8 

2.1 
1.8 

2.6 
2.3 
7.3 


0.3 
0.2 
0.9 
1.9 
0.8 
0.6 
1.1 

1.1 
1.2 
1.2 
1.2 

0.6 
0.7 
0.3 
0.4 
0.5 


Percl. 

0.5 
0.4 
0.7 
0.3 


1.0 


2.4 

0.8 

i.'s 

2.1 
0.6 
0.1 


0.3 
0.1 

0.1 
0.1 
0.3 
0.7 
0.1 


Perci 

14.1 
12.7 
31.5 
9.7 

20.1 
19.1 
19.5 

18.9 
17.4 
12.6 

12.6 

49.9 

7.4 
7.0 


66.1 
62.5 

78.1 
74.2 

78.4 
70.6 
74.2 
60.5 
72.9 

73.3 
62.2 

76.1 
68.5 
80.2 


54.4 
37.2 
17.3 
48.8 
56.4 
12.8 
21.1 

77.2 
59.8 
40.9 
58.5 

84.5 
10.8 
18.0 
.36.4 
22.3 


Percl. 
2.7 


1.8 
0.4 


>  a 

-i  3 


Perct.   OaU. 


0.4 
0.4 
0.9 
0.3 

0.5 
0.5 
0.6 

0.6 
0.5 
0.0 


0.6 
0.6 

0.3 
0.1 
0.4 


2.0 
2.4 
0.9 
4.5 

1.3 

1.2 
2.4 
1.2 
2.4 

2.3 
2.0 

3.4 
3.1 
2.6 


0.5 
0.7 
0.4 
2.8 
0.7 
0.4 
0.5 

0.7 
0.6 
1.1 
3.5 

0.3 
0.3 
0.3 
0.7 
0.5 


296 
260 
630 
200 

395 
370 
460 

370 
335 
255 

310 


180 
175 

140 

60 

390 


1.350 
1290 
1525 
1495 

1615 
1450 
1475 
1205 
1635 

1400 
1190 

1605 
1445 
1705 


1120 
730 
340 
1000 
1150 
275 
415 

1455 
1135 
785 
1116 

1585 
220 
355 
715 
430 


834        CHEMICAL  COMPOSITION'  OF  AMERICAN  FOOD  MATERIALS 


Food  materials. 


o  c  ^ 


a> 

a>  o 

S  P. 


Vbgetablk  Food  (Continued). 

FRUITS,    ETC.,   CANNED ;    AND 
JELLIES,  PRESERVES,  ETC. 

(Continued). 
Strawberries,  stewed,  as  pur- 
chased   

Tomato  preserves,  as  purch'd 


Almonds- 
Edible  portion 

As  purchased 

Beechnuts- 
Edible  portion 

As  purchased 

"Biotes"    (acorns)    (Quercus 
emonji) — 

Edible  portion      

As  purchased       

Brazil    nuts  (Bertkolletia   ex- 
celsa)— 

Edible  portion 

As  purchased 

Butternuts  (Jaglans  cinerea)— 

Edible  portion 

As  purchased 

Chestnuts,  fresh- 
Edible  portion 

As  purchased 

Chestnuts,  dried- 
Edible  portion 

As  purchased 

Cocoauuts— 

Edible  portion 

As  purchased 

Cocoanut,  without  milk,  as 
purchased 

Cocoanut-milk,  as  purchased 

Cocoanut,  prepared,  as  pur- 
chased   

Filberts- 
Edible  portion  

As  purchased 

Hickory  nuts- 
Edible  portion 

As  purchased 

Liehi  nuts- 
Edible  portion 

As  ])urchased 

Peanuts — 

Edible  portion 

As  purchased 

Peanut  butter,  as  purchased 

Pecans,  polished- 
Edible  portion 

As  purchased 

Pecans,  unpolished — 

Edible  portion 

As  purchased 

Pine  nuts— 
Pignolias,  edible  portion    . 
Piniones      (Pinus      mono- 
phylla) — 

Edible  portion 

As  purchased 

Piiion  fP(7?i(.«  pdulis) — 

Edible  portion 

As  purchased 


40, 


24 

53.2 
46.3 

41.7 
40.6 


Per  ct. 

74.8 
40.9 


Per  cl.  Per  ct 

0.7 

0.7 


4.5.0 
37.8 


5.9 
4.5 


14.1 
7.2 


8.9 
92.7 


3.7 

1.8 

3.7 
1.4 

17.9 
10.5 

9.2 
6.9 
2.1 

3.0 
1.4 


21.0 
11.5 


21.9 
13.0 


17.0 
8.6 


27.9 
3.8 


6.2 
5.2 


10.7 
8.1 


15.6 
7.5 

15.4 
5.8 

2.9 

1.7 

25.8 
19.5 
29.3 

11.0 
5.2 

9.6 

5.1 


6.5 
3.8 


14.6 
8.7 


54.9 
30.2 


57.4 
34.U 


37.4 
24.1 


66.8 
33.7 


61.2 
8.3 


50.6 
25.9 


31.7 

1.5 


65.3 
31.3 

67.4 
25.5 

0.2 
0.1 

38.fi 
29.1 
46.5 

71.2 
33.3 

70.5 
37.9 


60.7 
35.4 


61.9 
36.8 


Per  ct, 

24.0 
57.6 


13.2 

7.8 


48.0 
30.9 


42.1 
35.4 


74.2 
56.4 


27.9 
14.3 


17.5 
4.6 


13.0 
6.2 

11.4 
4.3 

77.5 
45.2 

24.4 

18.5 
17.1 

13.3 
6.2 

15.3 
8.2 


26.2 
15.3 


17.3 
10.2 


Per  cl.  Gala. 

0.5    460 
0.7   1090 


2.0  3030 

1.1  1660 


3.5 
2.1 


2.4 
1.6 


3.9 
2.0 


2.0 
0.4 


1.3 
1.1 


2.2 
1.7 


1.7 
0.9 


1.0 

0.8 


2.4 
1.1 

2.1 
0.8 

1.5 
0.9 

2.0 
1.5 
5.0 

1.5 
0.7 

1.9 

1.0 


2.8 
1.6 


2.8 
1.7 


3075 
1820 


2620 
1690 


3265 
1655 


3165 
430 


1125 
945 


1875 
1425 


2760 
1413 


1730 
155 


3290 
1575 

3345 
1265 

1505 
875 

2560 
1935 
2825 

3455 
1620 

3435 
1846 

2845 


3170 
1850 


3205 
1905 


CHEMICAL   COMI'OSITIOX   OF  AMEh'JCAX   FOOD  AJATFIiJALlS        835 


Food  materials 


Vbgetable  Food  (Continued). 

NUTS  (Continued). 
Pine  nuts  (Continued)— 
Sabine  pine  nut  (Pinus  sa- 
Iii7iiana) — 

Edible  portion 

As  purchased 

Pistaciiios— 
First  quality,  shelled,  edi- 
ble portion       . 
Second     quality,    shelled, 

edible  portion 

Walnuts,  California- 
Edible  portion 

As  purchased 

Walnuts,  California,  black — 

Edible  portion 

As  purchased 

Walnuts,     California,      soft 
shell- 
Edible  portion  .  .  .   .V.   . 

As  purchased 

"  Malted  nuts,"  as  purchased 

MISCELLANEOUS. 

Chocolate,  as  purchased  .   .   . 

Cocoa,  as  pvirchased 

Cereal  coffee  infusion  (1  part 
boiled  in  20  parts  water)  . 

Yeast,  compressed,  as  pur- 
chased   .  .  . 


^  en 

Is 

a  OS 


Per  ct. 


Per  ct. 
5.1 

1.2 


2.5 
1.0 
2.6 


6.9 
4.6 


98.2 
65.1 


Perct. 

28.1 
6.5 


22.3 

22.8 


18.4 
4.9 


27.6 
7.2 


16.6 
6.9 
23.7 


12.9 
21.6 


0.2 
11.7 


o  -  ^ 

its. 


Perct. 

53.7 
12.3 


54.0 
54.9 


64.4 
17.3 


56.3 
14.6 


63.4 
26.6 
27.6 


48.7 
28.9 


0.4 


Perd. 

8.4 
1.9 


16.3 
14.9 


13.0 
3.5 


11.7 
3.0 


16.1 
6.8 
43.9 


30.3 

37.7 


1.4 
21.0 


Perct. 


Perct. 
4.7 
1.1 


3.2 
3.0 


1.7 
0.5 


1.9 
0.5 


1.4 

0.6 
2.2 


2.2 

7.2 


0.2 
1.8 


CaU. 

2945 
675 


2995 
3020 


3380 

885 


:!105 
805 


3285 
1875 
2240 


2860 
2320 


30 
625 


<M 

Protein 

6  . 

«9 

s 

(-  <u 

3  3 

Food  materials. 

II 

<u 

si 

3 
<6 

S§ 

a 

?- 

He 

3  OS 

a 

« 

X 

a       ^ 

S3 

§s. 

^ 

PS 

is: 

13 

m 

fe 

H 

■< 

;>• 

Unclassified  Food 

Materials. 

animal  and  vegetable. 

Soups,  home-made. 

Per  ct. 

Perct. 

Perct. 

Per 

ct.  Perct. 

Perct. 

Perct. 

CaU. 

Beef  soup,  as  purchased  .  .  . 

2 

92.9 

*A 

0.4 

1.1 

1.2 

120 

Bean  soup,  as  purchased  .   .   . 

1 

84.3 

3.2 

1.4 

9.4 

1.7 

295 

Chicken  soup,  as  purchased 

1 

84.3 

10..T 

0.8 

2.4 

2.0 

275 

Clam  chowder,  as  purchased 

2 

88.7 

1.8 

0.8 

6.7 

2.0 

195 

Meat  stew,  as  purchased    .   . 

5 

84.5 

4.6 

4.3 

5.5 

1.1 

370 

Soups,  canned. 

Asparagus,  cream  of,  as  pur- 
chased   

1 

87.4 

2.5 

3.2 

5.5 

1.4 

285 

Bouillon,  as  purchased    . 

3 

96.6 

2.2 

0.1 

0.2 

0.9 

50 

Celery,  cream  of,  as  purch'd 

1 

S8.(; 

2.1 

2.8 

195 
100 

Chicken  gumbo,  as  purch'd  . 
Chicken  soup,  as  purchased 

2 
2 

89.2 

9;^.s 

3.8 
3.6 

0.1 

1.5 

1.0 

Consomme?,  as  purchased  . 

1 

96.0         2..'> 

Cream,  corn  of,  as  purchased 

1 

86.8         2..';   1 

1.9 

7.8 

Julienne,  as  purchased 

1 

g.^i.!*         2.7   1 

0.5 

0.9 

Mock  turtle,  as  purchased 

2 

89.8         5.2  j 

0.9 

2.8 

180 

Mulligatawny,  as  purchased 

2 

89.3 

3.7  1 

0.1 

5.7 

1.2 

836        CHEMICAL  COMPOSITIOy  OF  AMERICAN  FOOD  MATERIALS 


Food  materials. 


OS 

0)  >> 


Protein. 


03  ^ 


•9 
*  ft 


a  ft 


Unclassified  Food  Mate- 
EiALS  {Continued). 

ANIMAL  AND  VEGETABLE 

{Continued). 
Sovps,  canned  (Continued). 

Oxtail- 
Edible  portion 

As  purchased 

Pea  soup,  as  purchased  .  .   . 

Pea.  cream  of  green,  as  pur- 
chased   

Tomato  soup,  as  purchased  . 

Turtle,  green,  as  purchased  . 

Vegetable,  as  purchased   .  . 

Miscellaneous. 

Hash,  as  purchased 

"Infants'  and  invalids' 
foods,'' as  purchased'  .   . 

Mincemeat,  commercial,  as 
purchased 

Mincemeat,  home-made,  as 
purchased 

Salad,  ham,  as  purchased  .  . 

Sandwich,  egg,  as  purchased 

Sandwich,  chicken,  as  pur- 
chased   


Perct. 

i.'s 


Perct. 

88.8 
87.8 
86.9 

87.7 
90.0 
86.6 
95.7 


80.3 

6.0 

27.7 

54.4 
69.4 
41.4 

48.5 


Perct. 
4.0 


6.0 

12.7 

6.7 

4.8 
15.4 
9.6 

12.3 


Perct. 


Peret. 

1.3 
0.5 
0.7 

2.7 
1.1 
1.9 


1.9 

3.3 

1.4 

6.7 
7.6 
12.7 


Perct. 

4.3 
4.2 
7.6 

5.7 
5.6 
3.9 
0.5 


9.4 

76.2 

60.2 

32.1 
5.6 
34.5 

32.1 


Perct. 

1.6 
1.9 
1.2 

1.3 
1.5 
1.5 
0.9 


2.4 

1.8 

4.0 

2.0 
2.0 
1.3 


Perct 

210 
170 
235 

270 
185 
265 
65 


365 

1795 

1305 

970 
710 
1355 


1.7       1055 


*  This  includes  malted  milk,  infants'  foods,  and  similar  preparations  which 
are  sold  under  various  trade  names,  but  are  similar  in  composition. 


RAPID  REFERENCE  DIET-LISTS 


These  lists  have  been  inserted  to  enable  the  practitioner  to  make 
rapid  reference  when  so  desired.  Additional  lists  will  be  found  under 
the  headings  of  the  various  diseases.  Additions  and  changes  may  be 
made  to  suit  the  individual  patient.  It  is  convenient  to  have  a  printed 
form  containing  a  list  of  the  foods  usually  allowable  and  those  usually 
forbidden.  With  such  a  form  a  diet  may  be  easily  prescribed  by 
marking  off  all  articles  which  are  not  thought  desirable.  The  fol- 
lowing is  a  useful  list : 

All  foods  are  allowable  unless  marked  off  the  list. 


Soups. 

Bouillon, 
Beef  broth, 
Veal  broth, 
Mutton  broth, 
Chicken  broth. 

Thick  Soups. 

Mock  turtle, 

Mulligatawney, 

Fish  soups. 

Noodle, 

Vegetable, 

Julienne. 

Purees  and  Creams. 
Barley, 
Rice, 
Pea, 
Bean, 

Asparagus, 
Potato, 
Tomato, 
Celery, 
Onion. 


Fish. 


Boiled, 

Broiled, 

Baked, 

Bass, 

Bluefish, 

Carp, 

Cod, 

Flounder, 

Haddock, 

Halibut, 

Herring, 

Mackerel, 

Perch, 

Pickerel, 

Pompano, 

Salmon, 


Shad, 
Shad  roe, 
Trout, 
Turbot. 

Oysters. 
Raw, 
Panned, 
Broiled, 
Steamed, 
Stewed, 
Oyster  pate. 
Roast. 

Clams. 
Raw, 
Broth, 
Chowder. 

Shellfish,  etc. 
Crabs, 
Lobster, 
Frogs, 
Shrimp, 
Terrapin, 
Green  turtle. 

Meats. 
Boiled, 
Broiled, 
Hashed, 
Roast, 
Stewed, 
Beef, 

Raw  beef, 
Beefsteak, 
Mutton, 
Mutton  chops, 
Lamb, 

Lamb  chops, 
Veal, 
Pork, 
Bacon, 
Ham, 
Sausage, 

837 


Tongue, 

Brains, 

Sweetbreads, 

Liver, 

Kidney, 

Tripe. 

Poultry. 
Chicken, 
Turkey, 
Duck, 
Goose, 
Squab. 

Game. 
Partridge, 
Wild  duck, 
Rabbit, 
Squirrel, 
Venison. 

Eggs. 
Raw, 

Soft  boiled. 
Poached, 
Omelet, 
Scrambled. 

Milk. 
Whole, 
Skimmed, 
Peptonized, 
Buttermilk, 
Whey, 
Curd, 
Kumiss, 
Kefir, 
^latzoon. 
Cream, 
Boiled  milk. 
Pasteurized  milk. 
Milk  and  barley-water. 

Butter. 


Cream, 


Cheese. 


838 


RAPID  REFEREISCE  DIET-LIHTH 


American, 

Cheshire. 

Clieddar, 

Pineapple, 

Sweitzer, 

Roquefort, 

Camembert. 

Cereals,  etc. 

Oatmeal, 

Cracked  wheat, 

Rice, 

Barley. 

Farina, 

Corn  meal, 

Hominy, 

Buckwheat, 

Cereal  gruels. 

Sago, 

Tapioca, 

Macaroni, 

Spaghetti. 

Le(jumes 
Peas, 
Beans, 
Lima  beans, 
Green  beans. 
Navy  beans. 
Lentils. 

Roots  and  Tubers. 
Potatoes, 

Baked, 

Boiled, 

Mashed, 
Sweet  potatoes, 
Jerusalem  artichoke. 
Beets, 
Carrots, 
Parsnips, 
Turnips. 

Green  Vegetables. 
Cabbage, 
Cauliflower, 
Brussel  sprouts, 
Saner  kraut, 
Spinach, 
Vegetable  marrow, 


Sea  kale, 

Tomatoes, 

Lettuce, 

Endives, 

Sorrel, 

Chicory, 

Watercress, 

AsparagTis, 

Salsify, 

Rhubarb, 

Celery, 

Squash, 

Green  corn. 

Fruit. 

Raw, 

Stewed, 
Oranges, 
Lemons, 
Apples, 
Pears, 
Peaches, 
Bananas, 
Grapes, 
Plums, 
Prunes, 
Cherries, 
Olives, 
Pine  apples, 
]\Ielons, 
Dates, 
Figs, 
Berries. 

Nuts. 

Breads. 
Stale, 
Toasted, 
Pulled, 
Zwieback. 
White  flour, 
(iraham  flour, 

Rye, 

Crackers, 
Gluten  bread. 

Desserts. 
Puddings, 
Bread, 
Cornstarch, 


Blanc  mange, 
Rice, 
Tapioca, 
Junket, 
Cup  custard, 

Ice  Cream. 
Vanilla, 
Chocolate, 
Fruit  flavors. 

Water  Ices. 
Lemon, 
Orange, 
Sherbet. 

Cakes. 
Sponge  cake, 
Lemon  jelly, 
Wine  jelly. 
Honey. 

Beverages. 
Egg-nog, 
Egg  broth, 
Albumin  water. 
Lemonade, 
Imperial  drink. 
Flaxseed  tea. 
Grape  juice, 
Oatmeal, 
Barley  water. 
Rice  water. 
Tea, 
Coffee, 
Chocolate, 
Cocoa. 

Mineral  Waters. 
Vichy, 

Lithia  water, 
AppoUinaris, 
White  Rock, 
Poland, 
Congress, 
Hathorne, 
Carlsbad. 

Alcoholic  Beverages.       * 
According   to   special   di- 
rections. 


It  is  frequently  found  advisable  to  have  a  list  of  the  articles  of  diet 
most  frequently'  forbidden.     The  following  will  be  found  useful: 


Rich  soups. 

Fried   foods. 

Pork, 

Veal, 

Stews, 

Hashes, 

Corned  meats, 

Potted  meats. 

Liver, 

Kidney, 

Duck," 


Goose, 

Sausage, 

Twice-cooked 

meats. 
Crabs, 

Preserved  flah. 
Smoked  fish. 
Salted  fish, 
Salmon, 
Salt  mackerel. 
Sardines, 


Cauliflower, 

Celery, 

Radishes, 


Sweet  potatoes, 

Beets, 

Salads, 

Hot  bread. 

Hot  cakes, 

Nuts, 


Candies, 
Pies, 
Pastries, 
Preserves, 
Strong  tea. 
Strong  coffee, 
Alcoholic        stimu- 
lants, 
Iced  water. 
Ice  cream. 


RAI'lD   h'Kl'IJh'EWf:  DlF/r-LliiTii  839 

FEVER 

General  Directions. — As  a  rule,  the  food  should  be  fluid  and  giveii 
It  regular  intervals  in  small  (luantities. 

May  take: 

Milk. — Milk  and  barley  water,  mailed  milk,  peptonized  milk,  kumisjs,  kefir, 
Imttermilk,  eyy-iiog    (small  quantity),  milk  puneli,  milk  Viehy. 

Soups. — L'lam  broth,  oyster  brolli.  chicken,  mutton  or  beef  broth,  beef  juice, 
beef-tea.  bouillon  wi'tli  egg.  liquid  beef  preparations,  as  panopepton.  liquid 
beef  i>eptonoids,  tonic  beef,  and  tlie  like.  These  should  be  diluted  with 
water. 

Eggs. — Albumin  water  with  llavoring  of  orange  or  lemon  juice,  witli  wine  as 
sherry  or  other  stimulants. 

Drinks. — Water,  lemonade,  cn-angeade.  grape  juice,  barley  water,  rice  water, 
Vichy,  Apollinaris,  Poland  White  Rock. 

DYSPEPSIA  AND  CHRONIC   GASTRITIS 
May  take : 

Soups. — Mutton,  chicken,  beef,  oyster,  bouillon,  rice,  tapioca,  barley,  vermi- 
celli, clam. 

Meats. — Boiled  brains,  boiled  or  broiled  sweetbreads,  raw  scraped,  boiled,  or 
broiled  beef,  broiled  steak,  roast  beef  or  mutton,  broiled  chops,  roast  lamb, 
lainli  'liops,   l)oiled.   broiled,   or   roasted  chicken,   squab,   turkey,  birds. 

Fish. — Kaw,  broiled,  or  stewed  oysters,  boiled  or  broiled  mackerel,  rock,  bass, 
trout,  or  blue-rish 

Eggs. — Raw.  soft  boiled.  ]ioaclied. 

Vegetables. — Asparagus,  spinach,  peas,  string:  beans,  lima  beans,  (best  mashed 
and  strained)  potatoo  (baked  or  mashed),  turnips,  carrots  (mashed  and 
strained),  lettuce    iwitlumt  vinegar),  cresses    (without  vinegar). 

Farinaceous  Food. — Rice,  cornstarch,  sago,  tapioca,  arrowroot,  hominy,  grits, 
vermicelli,  cream  of  wheat,  stale  wheat  bread,  toast,  graham  bread,  corn 
liread.  pulled  bread,  zwieback. 

Desserts.  —  Blanc-mange,  hominy,  custards,  rice  pudding,  tapioca  pudding, 
bread  pudding. 

Fruits. — Lemons,  oranges,  raw,  baked,  or  stewed  apples,  grapes,  stewed 
apricots,  raw,  or  stewed,  peaches,  stewed  pears,  stewed  prunes,  stewed 
cherries. 

Fatty  Foods. — Butter,  cream,  pure  olive  oil. 

Drinks. — Taken  mainly  between  meals.  Milk,  buttermilk,  malted  milk,  pep- 
tonized milk,  milk  with  lime-water,  milk  with  Vichy,  milk  Havored  witii 
tea,  milk  Havored  with  coffee,  kefir,  kumiss,  junket,  whey,  cocoa,  albumin- 
water,  liot  water,  grape  juice. 

Mineral  Waters. — Vichy,  Apollinaris,  Poland,  Lithia  water,  Congress, 
Hathorne,  Carlsbad. 

Must  not  take: 

Ri("h  soups,  fried  foods,  pork,  veal,  stews,  hashes,  corned  meat,  potted  meat, 
liver,  kidney,  duck,  goose,  sausage,  crabs,  lobsters,  preserved  fish,  smoked 
tisli,  salted  fish,  salmon,  salt  mackerel,  sardines,  celery,  corn,  radish,  cab- 
bage, tomatoes,  cucumbers,  sweet  potatoes,  beets,  salads,  hot  bread  or 
cakes,  nuts,  candies,  pies,  pastry,  cheese,  strong  tea.  strong  coffee,  alco- 
holic stimulants,  ice-Avater,  ice-cream. 

DILATATION  OF  THE  STOMACH 
May  take : 

Meats. —  Boiled    brains,    boiled    or    broiled    sweetbreads,    raw    scraped    beef. 

i)roiled   steak,   roast   beef,   roast   lamb,   chops,    boiled,    broiled,   or   roasted 

chicken,  iiroiled  or  roasted  squab,  birds  or  tiu-key 
Fish. — Kaw,  broiled  or  stewed  oysters,  broiled  or  boiled  mackerel,  rock,  bass, 

trout,  or  blue-fish. 
Eggs. — Raw,  soft-boiled,  poached. 


840  RAPID  REFERENCE  DIET  LISTS 

Vegetables. — Asparagus,  spinach,  peas,  string  beans,  lima  beans  (best  mashed 
and  strained),  potatoes  (baked  or  mashed),  turnips,  carrots  (mashed  and 
strained ) ,  lettuce    ( without  vinegar ) ,  cresses    ( without  vinegar ) . 

Farinaceous  Food. — Eice,  cornstarcli,  sago,  tapioca,  arrowroot,  hominy,  grits, 
vermicelli,  cream  of  wheat,  stale  wheat  bread,  toast,  toasted  crackers,  corn 
bread,  pulled  bread,  zwieback. 

Desserts. — Blanc-mange,  custards. 

Fruits. — Baked  or  stewed  apples,  stewed  prunes. 

Fatty  Foods. — Butter   (small  quantity),  cream. 

Drinks. — Take  mainly  between  meals.  Milk,  malted  milk,  peptonized  milk, 
milk  flavored  witli  tea,  milk  flavored  with  coffee,  albumin-water,  water 
(not  with  meals). 

Must  not  take: 

Soups,  fried  foods,  pork,  veal,  stews,  hashes,  corned  meat,  potted  meat,  liver, 
kidney,  duck,  goose,  sausage,  crabs,  lobsters,  preserved  fish,  smoked  fish, 
salted  fish,  salmon,  salt  mackerel,  sardines,  cauliflower,  celery,  radishes, 
corn,  cabbage,  cucumber,  tomatoes,  sweet  potatoes,  beets,  salads,  hot  bread 
or  cakes,  nuts,  candies,  pies,  pastry,  cheese,  strong  tea,  strong  coffee,  alco- 
holic stimulants,  ice-water,  ice-cream. 

ATONY  OF  THE  STOMACH 
May  take: 

Meats. — Boiled  brains,  boiled  or  broiled  sweetbreads,  raw  scraped,  boiled  or 
broiled  beef,  broiled  steak,  roasted  mutton,  broiled  chops,  roast  lamb,  boiled, 
broiled  or  roasted  chicken,  broiled  or  roasted  squab,  roast  turkey,  broiled 
or  roast  birds. 

Fish. — Raw,  broiled,  or  stewed  oysters,  broiled  or  boiled  mackerel,  rock,  bass, 
trout  or  blue-fish. 

Eggs. — Raw,  soft-boiled,  or  poached. 

Vegetables. — Asparagus,  spinach,  peas,  string  beans,  lima  beans  (best  mashed 
and  strained),  potatoes  (baked  or  mashed),  turnips,  carrots,  lettuce  (with- 
out vinegar),  cresses   (without  vinegar). 

Farinaceous  Foods. — Rice,  cornstarch,  sago,  tapioca,  arrowroot,  hominy, 
grits,  vermicelli,  cream  of  wheat,  stale  wheat  bread,  toast,  graham  bread, 
corn  bread,  pulled  bread,  zwieback. 

Desserts. — Blanc-mange,  honey,  custards,  rice  pudding,  tapioca  pudding, 
bread  pudding. 

Fruits. — Lemons,  oranges,  raw  (scraped),  baked  or  stewed  apples,  grapes, 
stewed  apricots,  raw  or  stewed  peaches,  stewed  pears,  stewed  prunes,  figs. 

Fatty  Foods. — Butter,  cream. 

Drinks. — Taken  mainly  between  meals.  Milk,  buttermilk,  malted  milk,  pep- 
tonized milk,  milk  with  lime-water,  milk  with  Vichy,  milk  flavored  with 
tea,  milk  flavored  with  coffee,  kefir,  kumiss,  junket,  whey,  cocoa,  albumin- 
water,  water   (not  with  meals),  hot  water,  grape  juice. 

Must  not  take: 

Soups,  fried  foods,  pork,  veal  stews,  hashes,  corned  meat,  potted  meat,  liver, 
kidney,  duck,  goose,  sausage,  crabs,  lobsters,  preserved  fish,  smoked  fish, 
salmon,  salt  mackerel,  sardines,  cauliflower,  celery,  radishes,  cabbage,  cu- 
cumber, sweet  potatoes,  beets,  salads,  hot  bread  or  cakes,  nuts,  candies, 
pies,  pastry,  cheese,  strong  tea,  strong  coffee,  alcoholic  •  stimulants,  ice- 
water,  ice-cream. 

HYPERCHLORHYDRIA  OR  HYPERACIDITY 
May  take : 

Meats. — Boiled  or  broiled  brains,  raw  scraped  beef,  boiled  or  broiled  beef, 
broiled  steak,  roast  mutton,  broiled  chops,  roast  lamb,  boiled,  broiled  or 
roasted  chicken,  broiled  or  roasted  squab,  roast  turkey,  broiled  or  roasted 
birds. 

Farinaceous  Foods. — Rice,  cornstarch,  sago,  tapioca,  arrowroot,  hominy,  grits, 
vermicelli,  cream  of  wheat,  stale  wheat  bread,  toast,  corn  bread,  pulled 
bread,  zwieback. 


RAPID  REFERENCE  DlET-LISTS  841 

Fruits. — Baked  or  stewed  apples,  stewed  apricots,  stewed  peaches,  stewed 
pears,  stewed  prunes. 

Fatty  Foods. — Butter,  cream,  pure  olive  oil. 

Drinks. — Taken  mainly  between  meals.  :Milk,  buttermilk,  malted  milk,  pep- 
tonized milk,  milk  with  lime-water,  milk  with  Vichy,  milk  flavored  with 
tea,  milk  flavored  with  coflee,  ketir,  kumiss,  junket,  whey,  cocoa,  albumin- 
water,  Avater    (not  with  meals),  hot  water. 

Mineral  Waters. — Vichy,  Apollinaris,  Poland,  Lithia  water,  Congress, 
Hathorne,  Carlsbad. 

Must  not  take: 

Soups,  fried  foods,  pork,  veal,  stews,  hashes,  corned  meat,  potted  meat,  liver, 
kidney,  duck,  goose,  sausage,  crabs,  lobsters,  preserved  fish,  smoked  fish, 
salmon,  salt  mackerel,  sardines,  cauliflower,  celery,  cocoa,  radishes,  cu- 
cumbers, sweet  potatoes,  beets,  tomatoes,  acid  fruits,  salads,  hot  bread  or 
cakes,  nuts,  candies,  pies,  pastry,  cheese,  strong  tea,  strong  coffee,  alcoholic 
stimulants,  ice-water,  ice-cream. 

ULCER  OF  THE  STOMACH 

First  Week. — Broth,  mutton,  chicken,  beef,  oysters,  bouillon,  flour. 

Eggs. — Raw  or  in  bouillon. 

Drinks. — Milk  with  Vichy,  milk  with  lime-water. 

Second  Week. — Broths. — Mutton,  chicken,  beef,  oyster,  bouillon,  flour,  rice, 

barley. 
Eggs. — Raw  or  in  bouillon,  soft-boiled. 
Drinks. — Milk  with  Vichy  or  lime-water. 
Farinaceous    Foods. — Bread,    milk-toast,    rice    served    in    milk    or    bouillon, 

tapioca  served  in  milk  or  bouillon. 
Third  Week. — Broths. — Mutton,  chicken,  beef,  oyster,  bouillon,  tapioca,  rice, 

barley,  clam,  vermicelli. 
Meats. — Brains  boiled,  sweetbreads  boiled,  broiled,  beef  raw,  scraped,  broiled 

steak,  lamb  chops,  chicken,  boiled,  broiled,  squab  broiled. 
Fish. — Raw,  broiled,  or  stewed  oysters,  boiled  rock  or  bass. 
Eggs. — Raw,  soft  boiled. 
Farinaceous  Foods. — Rice,  cornstarch,  sago,  tapioca,  arrowroot,  grits,  cream 

of  wheat,  toast,  zwieback. 
Fatty  Foods. — Butter. 
Drinks. — Milk,  malted  milk,  peptonized  milk,   milk  with  Vichy,  milk  with 

lime-water,   milk    with    tea,   milk    in   coflee,   kefir,   kumiss,   junket,   whey, 

cocoa,  albumin-water,  Apollinaris. 

Fourth  W^eek. 
May  take : 

Soups. — Mutton,  chicken,  beef,  oyster,  bouillon,  rice,  tapioca,  barley,  vermi- 
celli, clam. 

Meats. — Boiled  brains,  boiled  or  broiled  sweetbreads,  raw  scraped,  boiled  or 
'  broiled  beef,  broiled  steak,  roast  beef,  roast  mutton,  broiled  mutton  chops, 
roast  lamb,  lamb  chops,  boiled,  broiled,  or  roasted  chicken,  broiled  or 
roasted  squab  or  other  birds. 

Fish. — Raw,  broiled,  or  stewed  oysters,  broiled  or  boiled  mackerel,  rock,  bass, 
trout  or  blue-fish. 

Eggs. — Raw%  soft-boiled,  poached. 

Vegetables. — Asparagus,  spinach,  peas  (mashed  and  strained),  potatoes 
(baked  or  mashed),  turnips,  carrots   (mashed  and  strained). 

Farinaceous  Foods. — Rice,  cornstarch,  sago,  tapioca,  arrowroot,  hominy,  grits, 
vermicelli,  cream  of  wheat,  stale  wheat  bread,  toast,  corn  bread,  pulled 
bread,  zwieback. 

Desserts. — Blanc-mange,  custards,  rice  pudding,  tapioca  pudding,  bread  pud- 
ding. 

Fatty  Foods. — Butter,  cream,  pure  olive  oil. 

Drinks. — Milk,  buttermilk,  malted  milk,  peptonized  milk,  milk  with  lime- 
water,  milk  with  Vichy,  milk  flavored  with  tea,  milk  flavored  with  coffee, 
kefir,  kumiss,  junket,  whey,  cocoa,  albumin-water,  water  (not  with  meals). 


842  RAPID  REFERENCE  DIET-LISTS 

hot  water,  grape  juice.  Mineral  waters. — Vichy,  ApoUinaris,  Poland, 
Carlsbad. 

CHRONIC  DIARRHEA 

May  take: 

Soups. — Mutton,   chicken,   oyster,    bouillon,    rice,   tapioca,    barley,   vermicelli, 

clam. 
Meats. — Boiled    brains,    boiled    or    broiled    sweetbreads*,    raw    scraped    beet, 

broiled  steak,  roast,  broiled  mutton  chops,   lamb  chops,   boiled  or  broiled 

cliicken.  broiled  siiuab,  roast  iiirkey,  broiled  l)irds. 
Fish. — Raw.  broiled,  or  stewed  oysters,  broiled  or  boiled  mackerel,  rock,  bass, 

trout  or  blue-tisli. 
Eggs. — Kaw,  soft-boiled,  poached. 
Vegetables. — Asparagus,    spinach,    peas     (mashed    and    strained),    potatoes 

(baked  or  mashed) . 
Farinaceous    Foods. — Rice,    cornstarch,    sago,    tapioca,    arrowroot,    hominy, 

grits,  vermicelli,  cream  of  wheat,  stale  wheat  bread,  toast,  pulled  bread, 

zwieback. 
Desserts. — Blanc-mange,  custards,  rice  pudding,  tapioca  pudding,  bread  pud- 
ding. 
Fatty  Foods. — Butter   (small  quantity). 
Drinks. — Milk   (boiled),  malted  milk,  peptonized  milk,  milk  with  lime-water, 

milk  tlavored  with  tea,  junket,  whey,  cocoa  (Acorn),  albumin-water,  water 

(not  with  meals) . 
Alcoholic  Stimulants. — Port  wine,  brandy  at  times. 

Must  not  take: 

Rich  soups,  fried  foods,  pork,  veal,  stews,  hashes,  con.ed  meat,  potted  meat, 
liver,  kidney,  duck,  goose,  sausage,  crabs,  lobsters,  preserved  fish,  smoked 
fish,  salted  fish,  salmon,  salt  mackerel,  sardines,  caulirtower,  celery,  rad- 
ishes, tomatoes,  cabbage,  corn,  cucumbers,  sweet  potatoes,  beets,  salads, 
hot  bread  or  cakes,  nuts,  candies,  pies,  pastry,  cheese,  strong  tea,  strong 
coffee,  alcoholic  stimulants,  ice-water,  ice-cream,  oatmeal,  graham  bread, 
fruits. 

CHRONIC   CONSTIPATION 
May  take : 

Soups. — ^Mutton,  chicken,  beef,  oyster,  bouillon,  rice,  tapioca,  barley,  vermi- 
celli, clam. 

Meats. — Boiled  brains,  boiled  or  broiled  sweetbreads,  raw  scraped,  boiled,  or 
broiled  beef,  broiled  steak,  roast  beef,  roast  mutton,  broiled  mutton  chops, 
roast  lamb,  lamb  chops,  boiled,  broiled,  or  roasted  chicken,  broiled  or  roast 
squab,  roast  turkey,  broiled  birds. 

Fish. — Raw,  broiled,  stewed,  or  panned  oysters,  broiled,  boiled,  or  baked 
mackerel,  rock,  bass,  trout,  blue-tish,  eggs. 

Vegetables. — Asparagus,  boiled  onions,  celery,  spinach,  peas,  corn,  string 
beans,  lima  beans,  tomatoes,  potatoes,  sweet  potatoes,  turnips,  carrots, 
caulitlower.  lettuce,  cresses,  sauer-kraut. 

Farinaceous  Foods. — Oatmeal,  cornstarch,  sago,  tapioca,  hominy,  grits,  vermi- 
celli, cream  of  wheat,  wheat  bread,  graham  bread,  corn  bread,  brown  bread, 
rye  bread. 

Desserts. — Ice  cream,  blanc-mange,  honey,  syrup,  custards,  rice  pudding, 
tapioca  pudding,  bread  pudding. 

Fruits. — Lemons,  oranges,  raw,  baked  or  stewed  apples,  grapes,  apricots, 
raw  or  stewed  peaches,  stewed  pears,  prunes,  or  cherries,  figs. 

Fatty  Foods. — Butter,  cream,  pure  olive  oil. 

Drinks. — Taken  mainly  between  meals.  Milk,  buttermilk,  malted  milk,  milk 
flavored  with  tea,  milk  flavored  with  coffee,  kefir,  kumiss,  junket,  whey, 
albumin-water,  water  (not  with  meals),  hot  water,  grape  juice,  cider. 
Mineral  Waters. — Vichy,  ApoUinaris,  Poland.  Lithia  water.  Congress. 
Mathorne,  Carlsbad. 

Must  not  take: 

Tea,  claret,  cocoa,  chocolate,  rice,  barley  or  farina  gruels,  huckleberries, 
cheese,  alcoholic  stimulants. 


RAPID  liEFEUEM'E  D/ET-LISTS  843 

DEBILITY  AND  ANEMIA 

May  take: 

Thickened    Soups. — Mutton,    chicken,    beef,    oyster,    bouillon,    rice,    tapioca, 

l)iuiey.  vermicelli,  vcjietable. 
Meats.— Raw  scraped  beef,  chopped,  boiled,  or  rare  broiled  steak,  rare  roast 

beef,  roast  mutton,  broiled  cliops.   roast    himb.   lamb  chops,  boiled,  broiled, 

or  roast  chicken,  broiU'd  or  roasted  s(iual). 
Fish. — Raw,  broiled,  or  stewed  oysters,  broiled  or  boiled  mackerel,  rock,  bass, 

trout   or  l)lue-lish. 
Eggs. — Raw  and  with  sherry,  soft  boiled,  poached,  scrambled. 
Vegetables. — Asparagus,    spinach,    peas,    string   beans,    lima   beans,   potatoes 

( liakcd    or    nmshed) .    tomatoes,    raw,    lettuce    (without    vinegar),    cresses 

(witliout   vinegar),  celery,  onions. 
Farinaceous     Foods. — Rice,     cornstarch,     sago,     tapioca,     arrowroot,     mush, 

iiominy,   rolled   oats,   grits,   cakes,   vermicelli,    macaroni,   cream   of   wheat, 

pulled  bread,  zwieback,  brown  bread. 
Desserts. — Blancmange,   honey,  jellies  and  jams,  custards,  marmalades,   rice 

pudding,  tapioca  pudding,  bread  pudding,  calfs-foot  jelly. 
Fruits. — Lemons,    oi'anges,    raw,    baked,    or    stewed    apples,    grapes,    raw    or 

stewed    apricots,    raw    or    stewed    peaches,    raw    or    stewed    pears,    stewed 

jjrunes,  raw  or  stewed  cherries,  figs. 
Fatty  Foods. — Butter,  cream,  pure  olive  oil.  cod  liver  oil. 
Drinks. — Milk,   buttermilk,   malted   milk,   peptonized   milk,   milk   with    lime- 
water,  milk  with  Vichy,  milk  flavored  with  tea,  milk  flavored  with  coffee, 

kefir,  kumiss,  junket,  whey,  chocolate    (vigor),  albumin-water,  water    (not 

with  meals),   grape  juice,   malt   extract.     Mineral    Waters. — Vichy,   Apol- 

linaris,  Poland.  White  Rock. 

Must  not  take: 

Thin  soups,  pork,  veal,  stews,  hashes,  corned  meat,  turkey,  sausage,  cabbage, 
turnips,  cucumbers,  carrots,  sweet  potatoes,  pickles,  salads,  bananas,  can- 
dies, pies,  pastry,  strong  teas,  strong  cofl'ee.  alcoholic  stimiilants. 

OBESITY 
General    Directions. — Avoid   sugars   and   starchy   foods   and   take 
little  or  uo  fatty  food.     Eat  sparingly  and  take  but  little  fluid,  and 
that,  apart  from  meals. 

May  take : 

Soups  (small  quantity)  .—niicken,  beef,  oyster,  bouillon,  clam. 

Meats. — Once  daily,  lean  raw  scraped,  boiled,  broiled  beef,  broiled  steak  or 

roast  beef,  roast  mutton,  broiled  chops,   roast  lamb  or  lamb  chops,  boiled 

or  broiled  chicken. 
Fish. — Oysters,  raw,  boiled  mackerel,  boiled  rock,  boiled  trout. 
Eggs. — Soft-boiled,  poaciied. 
Vegetables    (best  mashed   and   strained). — Asparagus,   spinach,   peas,   string 

beans,   lima  beans,   tomatoes,  cabl)age,   cauliflower,   lettuce,   cresses,   celery, 

onions,  radishes,  olives. 
Farinaceous   Foods.— Stale   wheat    bread    (small   quantity),   zwieback,   toast 

(small   quantity),  graham  bread,  gluten  bread    (small  quantity). 
Fruits    (acid). — Lemons,  oranges,  raw  apples,  grapes,  raw  peaches,  cherries, 

berries. 
Drinks. — Water   (not  with  meals),  hot  water,  tea    (no  sugar  or  milk),  coffee 

(no    sugar    or    milk).     Mineral    Waters.- — Vichy,    Lithia    water,    Rubinat, 

Apenta,  Carlsbad. 

Must  not  take: 

Eich  soups,  fried  foods,  pork,  veal,  stews,  hashes,  corned  meat,  potted  meat, 
liver,  kidney,  duck,  goose,  sausage,  crabs,  lobsters,  preserved  fish,  smoked 
fish,  salted  fish,  salmon,  bluefish,  salt  mackerel,  herring,  hominy,  oatmeal, 
rice  puddings,  sardines,  celery,  potatoes,  turnips,  carrots,  parsnips,  sweet 


844  RAPID  REFERENCE  DIET-LISTS 

potatoes,  beets,  hot  bread  or  cakes,  nuts,  candies,  pies,  pastry,  alcoholic 
stimulants. 

DIABETES 

General  Directions. — Eat  meats,  eggs,  green  vegetables,  and  fatty 

foods,  and  avoid  sugars,  starchy  foods,  and  liver. 

May  take : 

Soups. — Chicken,  beef,  veal,  mutton,  oyster,  turtle,  terrapin,  clam  broth  (no 
flour ) . 

Meats. — All  kinds  except  liver.     Gelatin  jellies. 

Cheese. — All  kinds  of  cheese,  especially  cream  cheese. 

Fish. — All  kinds  of  fish  and  in  any  form,  oysters,  clams,  terrapin,  lobster, 
shrimp,  salt  fish,  unless  they  cause  too  great  thirst. 

Farinaceous  Foods. — Gluten  bread,  cakes,  biscuit  and  porridges,  almond 
cakes  and  bread.  Soya  bread. 

Vegetables. — Green  vegetables,  spinach,  lettuce,  romaine,  chicory,  sorrel, 
kale,  artichokes,  endives,  pickles,  cucumbers,  cranberries,  truffles,  mush- 
rooms. 

Vegetables  sometimes  allowable. — Green  string  beans,  cauliflower,  cabbage, 
sauerkraut,  slaw,  egg-plant,  vegetable  marrow,  asparagus,  onions. 

Fruits. — Acid  fruits  of  any  kind,  sour  apples,  sour  cherries,  sour  oranges, 
lemons,  grape-fruit,  goose-berries,  red  currants. 

Nuts. — All  sorts  of  oily  nuts,  as  cocoanut,  walnuts,  filberts,  almonds,  but- 
ternuts, pecans,  Brazil  nuts. 

Fatty  Foods. — Cream,  butter,  olive  oil,  cod  liver  oil,  bone  marrow. 

Drinks. — Tea  or  coffee  without  sugar,  alkaline  mineral  waters,  Rhine  wines, 
claret.  Burgundy,  brandy,  whiskey. 

Allowable  at  Times  under  Special  Directions. — Milk,  bread,  potatoes,  and 
oatmeal.      (See  Diet  cures  in  Diabetes.) 

Must  not  take: 

All  sweet  foods,  sugars,  confections,  and  the  like.     All  starchy  food,  as  rice, 

hominy,  and  foods  prepared  with  flour,  etc. 
Meats. — Liver,  pate  de  foie  gras. 
Vegetables. — Potatoes,  turnips,  beets,  carrots,  peas,  beans  (not  always  string 

beans),  cauliflower,  sweet  fruits^  dates,  grapes,  peaches,  prunes,  bananas, 

preserves,  and  jellies. 
Nuts. — Peanuts,  and  chestnuts. 
Beverages. — Sweet  Avines,  cider,  cordials,  beers,  porter. 

GOUT  AND  GOUTINESS 

General  Directions. — Take  moderate  quantities  of  plain  nutritious 
foods.  Avoid  excesses  of  meat,  all  rich  foods,  and  eat  only  moderate 
quantities  of  starches  and  sugars. 

May  take : 

Soups. — Meat  soups  in  small  quantities.  Mutton  (weak),  chicken  (weak),' 
beef  (weak),  oyster,  bouillon,  rice,  tapioca,  barley,  vermicelli,  clam,  vege- 
table. 

Lean  Meats. — Roast  mutton  chops,  lamb  chops,  boiled,  broiled,  or  roasted 
chicken,  broiled  or  roasted  squab,  ham,  bacon,  broiled  or  roasted  birds 
( once  a  day ) . 

Fish. — Raw,  broiled,  or  stewed  oysters,  boiled  or  broiled  rock,  bass,  trout  or 
bluefish. 

Eggs. — In  small  quantity,  coddled  or  soft  boiled. 

Vegetables. — Spinach,  young  peas,  string  beans,  potatoes  (baked,  small  quan- 
tity), turnips,  cauliflower,  cabbage,  lettuce  (without  vinegar),  celery, 
cresses   ( without  vinegar ) ,  onions. 

Farinaceous  Foods. — Rice  in  small  quantity,  oatmeal,  cornstarch,  sago, 
tapioca,  arrowroot,  hominy,  grits,  vermicelli,  cream  of  wheat,  stale  wheat 
bread,  toast,  graham  bread,  rye  bread,  corn  bread,  pulled  bread,  zwieback. 


liAI'ID  REFEREXCE  DIET-LISTH  845 

Desserts. — Blanc-mange  (no  sugar)  custards  (no  sugar),  rice  pudding  (no 
sugar),  tapioca  pudding  (no  sugar),  bread  pudding  (no  sugar),  milk  pud- 
ding. 

Fruits. — Lemons,  oranges,  apples  (tart)  raw,  baked  or  stewed,  stewed  apri- 
cots, raw  or  stewed  peaches,  stewed  prunes,  stewed  cherries.  Fruit  to  be 
stewed  without  sugar. 

Fatty  Foods. — Butter. 

Drinks. — Taken  mainly  with  meals.  Milk,  buttermilk,  peptonized  milk, 
milk  with  Vicliy,  milk  flavored  with  tea,  milk  flavored  with  coflee,  kefir, 
kumiss,  junket,  whey,  lime  juice  or  lemonade  without  sugar,  water,  hot 
water.  Mineral  Waters. — Vichy,  ApoUiuaris,  Poland,  Lithia  water,  Carls- 
bad. 

Must  not  take: 

Rich  soups,  fried  foods,  hard-boiled  eggs,  pork,  veal,  stews,  hashes,  turkey, 
corned  meat,  potted  meat,  liver,  kidney,  duck,  goose,  sausage,  crabs,  lob- 
sters, preserved  fish,  smoked  fish,  salted  fish,  salmon,  salt  mackerel,  sar- 
dines, radishes,  mushrooms,  asparagus,  tomatoes,  dried  beans,  old  peas, 
pickles,  sweet  potatoes,  beets,  hot  bread  or  cakes,  nuts,  candies,  preserves, 
pies,  pastry,  rich  puddings,  cheese,  strong  tea,  strong  coffee,  alcoholic 
stimulants,  sweet  wines,  ice-cream,  stewed  berries,  cider. 

ALBUMINURIA 
May  take : 

Soups. — Milk  soup  with  tapioca  or  rice,  gruels,  vegetable,  corn,  potato. 
Meats. — Chicken,  ham,  game,   bacon,  steak,  chops,   or  roast   beef    (sparingly 

once  daily) . 
Fish. — Fresh  fish,  boiled,  broiled,  clams   (raw),  oysters    (raw). 
Eggs. — Sparingly. 
Vegetables. — Cabbage,  spinach,  boiled  onions,  cauliflower,  young  peas,  string 

beans,  lettuce. 
Farinaceous   Foods. — Rice,   grits,   hominy,    oatmeal,    cream   of   wheat,    sago, 

tapioca,  potatoes,  wheat  bread,  toast,  stale  bread    (wheat),  milk-toast. 
Desserts. — Tapioca    pudding,    rice    pudding,    milk    pudding,    bread    pudding, 

custard. 
Fruits. — Lemons,  oranges,  raw,  baked,  or  stewed  apples,  grapes,  stewed  pears, 

stewed  prunes. 
Fatty  Foods. — Butter. 
Drinks. — Milk,  buttermilk,  malted  milk,  peptonized  milk,  milk  with  Vichy, 

kefir,   kumiss,   junket,   whey,   water    (not   with   meals),    hot   water,   grape 

juice.     Mineral  Waters. — Vichy,  Apollinaris,  Poland,  Lithia,  White  Rock. 

TUBERCULOSIS 
General  Directions. — It  is  important  to  take  meat,  milk,  and  eggs 
in  as  large  quantities  as  can  be  digested.     ^Milk,  or  milk  and  egg 
should  be  taken  between  meals.     Raw  meat  should  be  taken  daily. 

May  take: 

Soups. — Bouillon,  soups  made  with  milk,  clam  or  oyster  broth,  chicken,  beef, 

mutton,  rice,  tapioca,  or  vermicelli  broth. 
Fish. — Fresh  fish  of  all  kinds,  as  mackerel,  trout,  or  perch,  oysters. 
Meats. — Raw  beef,  rare  beef,  steaks,  chops,  roast   beef,   roast  mutton,   lamb 

chops,   chicken,    turkey,    fresh   game,    bacon,   ham,    Mosquera's    beef    meal, 

beef -juice. 
Eggs. — Raw,  poached,  boiled,  scrambled,  or  omelet. 
Vegetables. — Spinach,  cauliflower,  asparagus  tops,  peas,  green  string  beans, 

lima   beans,   lettuce,   crosses,   celery,   baked,   mashed   or   creamed   potatoes, 

onions,  tomatoes. 
Farinaceous    Foods. — Bread,    Graham    bread,    toast,    milk-toast,    zwieback, 

pulled  bread,  oatmeal,  rice,  grits,  hominy,  corn  meal  mush,   barley  gruel. 

Farinaceous  foods  should  not  be  taken  in  too  large  quantities. 


846  RAPID  BEFEKI-JNCJ'J  DlET-LWTti 

Fatty  Foods. — Cream,  butter,  olive  oil,  cod  liver  oil,  extract  of  red  bone- 
marrow. 

Fruits. — Oranges,  lemons,  raw,  baked,  or  stewed  apples,  grapes,  stewed  apri- 
cots, jiears  or  prunes,  raw  or  stewed  peaches. 

Desserts. — Blanc-mange,  custards,  tapioca,  sago,  bread  or  rice  pudding,  farina, 
wine  jelly,  junket,  cheese. 

Drinks. — Water,  carbonated  water,  milk,  buttermilk,  peptonized  milk,  kumiss, 
ketir,  whey,  cocoa,  chocolate   (\'igor),  albumin-water,  grape-juice,  Vichy. 

Must  not  take: 

Excesses  of  starches  and  sugars,  pork,  veal,  hashes,  twice-cooked  meats, 
potted  meats,  liver,  kidney,  salt  tish,  smoked  fish,  lobster,  hot  bread  and 
cakes,  fried  foods,  pies,  pastry. 

EPILEPSY 

Breakfast. — Any  sort  of  ripe  fresli  fruit.  Any  cereal,  as  oatmeal,  cracked 
wheat,  rice,  grits,  etc.  ."Soft-boiled,  poached,  or  scrambled  eggs,  or  an 
omelet.  Bread  and  butter.  Any  sort  of  plain  crackers  if  desii'ed.  Milk, 
buttermilk,  kumiss,  milk  and  Vichy  or  eggshake.  Phillip's  digestible 
cocoa. 

Dinner. — Soups. — Any  clear  soup,  consomme  or  bouillon,  chicken,  mut^^on, 
beef  or  oyster  broth,  vegetable  purees.  Avoid  rich  and  highly  seasoned 
soups. 

Meat. — Fish  or  meat,  but  not  l)oth.  Any  sort  of  fresh  fish,  baked,  boiled  or 
broiled.  Any  sort  of  plain  fresh  meat,  as  roast  beef,  or  mutton,  chops  or 
steak  or  fowl. 

Vegetables. — Potatoes,  parsnips,  celery,  tomatoes,  spinach,  peas,  string  beans, 
asparagus,  salsify,  lettuce,  squash,  macaroni,  rice,  spaghetti,  hominy 

Desserts. — Fresh  fruit,  plain  puddings,  or  junket,  ice-cream   or  water-ice. 

Supper. — Bread  and  l)utter,  cereals,  stewed  fruits,  liquids,  as  for  breakfast. 
If  working  or  taking  much  exercise,  eggs  or  oysters  may  be  allowed,  other- 
wise very  plain  suppers  are  to  be  preferred. 

Avoid: 

All  fried  foods,  all  rich  and  highly  seasoned  dishes,  pastry,  cake,  candies, 
hot  breads,  all  forms  of  alcohol,  coffee  and  tea,  pork.  All  foods  known  to 
disagree  with  the  patient,  and  all  indigestible  articles,  as  pork,  lobster, 
ham,  and  tlie  like. 

DIET  AFTER  NORMAL  CONFINEMENT 
Alloivable  for  First  Tivo  Days. 

Liquids. — Water  as  desired.     Milk,  beef,  or  chicken  broth,  with  or  without 
well-cooked  barley  or  rice,  albumin-water,  cocoa,  weak  tea  or  coffee.     Tea 
is  to  be  preferred  to  coffee,  as  the  latter  is  more  liable  to  cause  insomnia. 
Solids. — Bread  and  butter,  toast,  crackers,  milk-toast,  poached  or  soft-boiled 
egg,  well-cooked  cereals,  wine  .jelly,  custards,  and  junket. 
From  First  Tiro  Days  I'ntil  the  End  of  the  First  Week. 
Liquids. — As  above 

Solids.- — In  addition  to  above,  baked  or  mashed  potato,  fruits,  green  vege- 
tables, as  peas,  string  beans,  spinach,  etc  ,  in  moderation.  Rice,  tapioca, 
and  sago  puddings.  White  meat  of  fish,  either  broiled  or  boiled.  Fresh 
meat,  steaks,  chops,  roast  beef  or  mutton,  squab. 

Avoid: 

Any  food  which  previously  disagreed  with  the  patient,  and,  as  a  general  rule, 
pork,  veal,  meat  ste^s,  and  twice-cooked  meats,  cabbage,  cucumbers,  tur- 
nips, dried  beans,  corn,  strawberries,  unripe  or  stale  fruit  and  vegetables, 
and  all  highly  seasoned  and  complicated  dishes. 

Sample  Diets: 

Breakfa.st. — A  sliced  orange,  well -cooked  breakfast  cereal,  a  soft-boiled  egg 

and  toast.     Cocoa,  tea,  or  coffee. 
Dinner. — A  cup  of  meat  broth,  lamb  chops,  baked  potato,  well-cooked  spinach, 

a  cup  of  junket,      liread  and  I)utter.     ^lilk  to  drink 
Supper. — Minced  chicken  on  toast,   baked  apple  and  cream,  milk  to  drink; 

tea  if  desired. 


SAMPLE  PAMPHLET  OF  INFORMATION  FOR 
DISTRIBUTION  AMONG  THE  POOR  IN  SUMMER 

iXuKSE  the  baby;  mother's  milk  is  the  best  of  all  foods. 

Do  not  wean  the  baby  in  hot  weather. 

Remember  that  ten  bottle  babies  die  to  one  that  is  breast  fed. 

One-third  of  the  deaths  of  infants  and  young  children  occur  during 
the  hot  summer  months. 

Heat  kills  the  baby  chiefly  by  spoiling  the  milk  given  it. 

Nurse  the  baby  regularly-,  not  oftener  than  two  hours  during  the 
da.y  and  four  hours  at  night. 

Do  not  nurse  the  baby  every  time  it  cries. 

If  you  cannot  nurse  your  baby,  consult  your  doctor  before  giving  it 
the  bottle. 

Fresh  Air. — Give  the  baby  fresh  air  day  and  night. 

Keep  the  windows  open  all  day  and  all  night. 

Keep  the  baby  out  of  doors  as  much  as  you  can. 

The  out-door  air  is  better  for  the  baby  than  that  of  the  house. 

The  air  in  the  squares  and  parks  is  better  than  that  of  the  streets. 

Keep  the  rooms  clean. 

Do  not  let  garbage,  slop,  or  dirty  clothes  stand  about  the  room. 

iSleep. — Do  not  let  the  baby  sleep  in  the  same  bed  with  any  other 
person. 

Keep  the  baby  quiet  and  let  it  sleep  as  much  as  it  will. 

Do  not  handle  the  baby  too  much,  let  it  alone. 

Bathing. — Bathe  the  baby  every  day. 

In  very  hot  weather  sponge  the  baby  several  times  a  day  to  keep  it 
clean  and  cool. 

Wash  the  baby  whenever  the  diapers  are  changed. 

Clothing. — The  baby  feels  the  heat  as  much  or  more  than  you. 

In  hot  weather  take  oft'  most  of  the  baby 's  clothing. 

If  it  becomes  cold,  the  clothing  can  easily  be  put  back. 

If  the  baby  has  fever,  take  some  of  the  clothing  off,  but  do  not  put 
more  on.     A  baby  with  fever  will  not  catch  cold. 

Diapers. — ^Wash  the  diaper  as  soon  as  it  is  soiled  and  dry  in  the 
open  air. 

Do  not  use  a  diaper  a  second  time  before  washing  it. 

Water. — In  hot  weather  the  baby  needs  a  little  more  water  and  not 
so  much  food. 

Give  a  few  teaspoonfuls  of  pure  boiled  water  several  times  a  day. 

Summer  diarrhea  is  caused  by  spoiled  milk  or  other  food,  bad  air, 

847 


848  SAMPLE  PAMPHLET  OF  INFORMATION 

dirt,  and  too  much  clothing,  too  much  handling,  too  little  sleep,  too 
little  water. 

If  the  baby  vomits  or  has  loose  bowels,  stop  all  food  and  give  plain 
boiled  water  until  you  have  seen  your  doctor. 

Do  not  drug  the  baby.  If  your  baby  is  sick  send  for  a  doctor  or 
take  it  to  a  hospital  or  dispensary. 

Do  not  ask  your  neighbors '  advice  about  your  baby,  ask  your  doctor. 

THE  BOTTLE-FED  BABY 

The  Bottles. — Use  a  common  round-bottomed  bottle;  boil  or  scald 
it  each  time  before  putting  the  baby's  milk  in  it. 

The  Nipples. — Use  plain  black  rubber  nipples.  Boil  them  once  a 
day.  Wash  the  nipples  before  and  after  each  feeding.  When  not  in 
use  keep  the  nipples  in  a  covered  glass  tilled  with  water  in  which  you 
have  put  a  pinch  of  baking  soda  or  borax. 

Never  use  a  nipple  with  a  tube  to  it. 

The  Milk. — Get  only  the  best  milk  for  the  baby.  Better  pay  more 
for  milk  and  save  doctor  bills,  and  possibly  funeral  expenses.  It  costs 
less  to  buy  a  baby  good  milk  for  a  year  than  to  bury  it. 

The  best  milk  is  bottled  at  the  dairy  and  delivered  in  bottles.  Milk 
sold  from  the  can  is  apt  to  be  dirty  and  unfit  for  use.  Milk  in  sum- 
mer from  an  open  can  in  a  shop  is  never  fit  to  give  a  baby. 

Milk  from  a  herd  is  better  than  milk  from  one  cow. 

To  Keep  Milk. — Take  it  in  as  soon  as  delivered.  As  soon  as  pos- 
sible mix  the  baby's  milk.  Place  this  in  clean  bottles  and  stopper 
with  raw  cotton. 

Keep  the  milk  cold — on  ice  if  possible.  If  you  have  no  ice,  wrap 
a  cloth  wrung  out  in  cold  water  about  the  bottles. 

If  you  have  difficulty  in  keeping  milk,  bring  it  to  a  boil  as  soon  as 
it  is  delivered  to  you. 

Keep  the  things  for  the  baby's  milk  separate. 

Keep  the  things  clean. 

Scald  them  with  boiling  water  before  using, 
if  it  is  not  kept  cold, 
if  it  is  not  kept  covered, 
if  it  is  dirty. 

if  it  has  been  put  in  dirty  bottles  or  cans, 
if  it  is  measured  in  dirty  cans, 
if  it  gets  dust  in  it. 


Milk  will  spoil 


WEIGHTS  AND  MEASURES 


Relative  Value  of  Apothecaries'  and  Metric  Measure. 


Minims. 

Cubic  centimeterB. 

Minims. 

Cubic  centimeters. 

u 

S 
S 

2 

"3 

£ 

CD 

B 
a 
u 

V 

3 
O 

V 

a 

3 

o 
!2 

3 

s 

2 

<o 

a 

c 

Ol 

o 
o 

s 

3 
O 

1  =  0.06 

30  =  1.90 

1  = 

30.00 

21  = 

621.00 

2  =  0.12 

35  =  2.16 

2  = 

59.20 

22  = 

650.00 

3  =  0.18 

40  =  2.50 

3  = 

89.00 

24  = 

710.00 

4  =  0.24 

45  =  2.80 

4  = 

118.40 

25  = 

740.00 

5  =  0.30 

50  =  3.08 

5  = 

148.00 

26  = 

769.00 

6  =  0.36 

55  =  3.40 

6  = 

178.00 

27  = 

798.07 

7  =  0.42 

7  = 

207.00 

28  = 

828.80 

8  =  0.50 

Fluid- 

8  = 

236.00 

30  = 

887.25 

9  =  0.55 

drams. 

9  = 

266.00 

31  = 

917.00 

10  =  0.60 

1  =  3.75 

10  = 

295.70 

32  = 

946.00 

11  =  0.68 

U  =  4.65 

12  = 

355.00 

48  = 

1419.00 

12  =  0.74 

IJ  =  5.60 

13  = 

385.00 

56  = 

1655.00 

13  =  0.80 

1|  =  6.51 

14  = 

414.00 

64  = 

1892.00 

14  =  0.85 

2  =  7.50 

15  = 

444.00 

72  = 

2128.00 

15  =  0.92 

3  =  11.25 

16  = 

473.11 

80  = 

2365.00 

16  =  1.00 

4  =  15.00 

17  = 

503.00 

96  = 

2839.00 

17  =  1.05 

5  =  18.50 

18  = 

532.00 

112  = 

3312.00 

18  =  1.12 

6  =  22.50 

19  = 

591.50 

128  = 

3785.00 

19  =  1.17 

7  =  26.00 

20  =  1.25 

25  =  1.54 

Relative  Value  of  Metric  and  Apothecaries'  Measure. 


s 

o6 

® 

a 

s 

a> 

at 

<a 

2 

s 

m 

a 

00 

a 

a 

■V 
a 

S 

§ 

a 

3 

a 

(V 

o 

a 

3 

8 

c 

oi 

s 

2 

3 

2 

3 

2 
"3 

3 

a 

a 

a 

3 

3 

•^ 

o 

CE4 

O 

^ 

O 

^ 

o 

S 

1000  = 

33.81 

400  = 

13.53 

25  = 

6.76 

4 

64.80 

900  = 

30.43 

300  = 

10.14 

10  = 

2.71 

3   = 

48.60 

800  = 

27.05 

200  = 

6.76 

9  = 

2.43 

2   = 

32.40 

700  = 

23.67 

100  = 

3.38 

8  = 

2.16 

1 

16.23 

600  = 

20.29 

75  = 

2.53 

7  = 

1.89 

0.50  = 

8.11 

500  = 

16.90 

50  = 

1.69 

6  = 

1.62 

0.25  = 

4.06 

473  = 

16.00 

30  = 

1.01 

5  = 

1.35 

0.06  = 

1.00 

54 


849 


850 


WEIGHTS  AND  MEASURES 


Eelaiive  Value  of  Avoirdupois  and  Metric  Weight. 

Avoir, 
ounces. 

Grams. 

^^°^^-       Grams, 
ounces.      "'"""• 

Avoir, 
ounces. 

Grams. 

Avoir. 
pounds. 

Grams. 

t; 

1.772 

5  =   141.75 

13      = 

368.54 

3   = 

1360.78 

3.544 

6   =   170.10 

14      = 

396.90 

4   = 

1814.37 

J  = 

7.088 

7   =   198.45 

15      = 

425.25 

5   = 

2267.55 

i  = 

14.175 

8  =  226.80 

6  = 

2721.55 

1    = 

28.350 

9  =  255.15 

pounds. 

7  = 

3175.14 

2     = 

56.700 

10   -=   283.50 

1.0  = 

453.60 

8  = 

3628.74 

3     = 

85.050 

11   =  311.84 

2.0  = 

907.18 

9   = 

4082.33 

4      = 

113.400 

12  =  340.20 

2.2  = 

1000.00 

10  = 

4535.92 

Relative  Value  of  Metric  and  Avoirdupois   Weight. 


Gm.    Ounces.  Grains. 

Gm.    Ounces.    Gr. 

Gm. 

Ounces.    Gr. 

Gm.    Ounces.    Gr. 

28.35  =   1 

38   =   1   +   149 

125 

=     4+179 

600  =  21  +     72 

29.00  =   1+10 

39   =   1   +   164 

150 

=     5+127 

650  =  22  +  405 

30.00  =   1+25 

40  =   1   +   180 

200 

=    7+24 

700  =  24  +  303 

32.00  =   1+56 

50   =    1   +   334 

250 

=    8+358 

750  =  26  +  198 

33.00  =   1+72 

60   =   2   +     50 

300 

=  10  +  255 

800  =  28  +    96 

34.00  =   1+87 

70  =  2  +  205 

350 

=  12  +  152 

850  =  29  +  429 

35.00   =   1   +   103 

80  =  2  +  300 

400 

=  14  +    48 

900  =  31  +  326 

36.00  =   1   +   118 

85  =  3 

500 

=  17  +  279 

950  =  33  +  222 

37.00  =  1  +  133 

100  =  3  +  230 

550 

=  19  +  175 

1000  =  35  +  120 

Bdative  Value  of  Apothecaries^  and  Metric  Weight. 


Oiains. 

Grams. 

Grains. 

Grams. 

Drams. 

GramB. 

1 

_ 

0.0625 

24 

_ 

1.55 

1 

_, 

3.90 

2 

= 

0.1300 

25 

<= 

1.62 

2 

= 

7.80 

3 

= 

0.1950 

26 

= 

1.70 

3 

= 

11.65 

4 

=- 

0.2600 

27 

= 

1.75 

4 

= 

15.50 

5 

= 

0.3240 

28 

= 

1.82 

5 

= 

19.40 

6 

= 

0.4000 

30 

z= 

1.95 

6 

= 

23.30 

7 

= 

0.4600 

32 

=^ 

2.10 

7 

= 

27.20 

8 

= 

0.5200 

33 

= 

2.16 

Ounces. 

9 

= 

0.6000 

34 

= 

2.20 

1 

= 

31.10 

10 

=- 

0.6500 

35 

= 

2.25 

2 

= 

62.20 

11 

= 

0.7150 

36 

= 

2.30 

3 

= 

93.30 

12 

= 

0.7800 

38 

= 

2.47 

4 

= 

124.40 

14 

= 

0.9070 

39 

= 

2.55 

5 

= 

155.50 

15 

= 

0.9720 

40 

= 

2.73 

6 

= 

186.60 

15.5 

= 

1.0000 

44 

= 

2.86 

7 

= 

217.70 

16 

= 

1.0400 

48 

= 

3.00 

8 

= 

248.80 

18 

= 

1.1600 

50 

= 

3.25 

9 

= 

280.00 

20 

= 

1.3000 

52 

= 

3.40 

10 

= 

311.00 

21 

= 

1.3600 

56 

= 

3.65 

48 

= 

1492.80 

22 

= 

1.4250 

58 

= 

3.75 

100 

" 

3110.40 

1  = 

2  ^ 

3  =z 

4  r= 

5  = 


Btlaiive  Value  of  Metric  and  Avoirdupois   Weight. 


15.43 
30.86 
46.30 
61.73 
77.16 


6 

— 

92.60 

lUO 

= 

1543.23 

7 

^= 

98.02 

125 

^^ 

1929.04 

8 

— 

123.46 

150 

— 

2374.85 

9 

— 

138.90 

175 

=r 

2700.65 

10 

z^ 

154.32 

1000 

=z 

15432.35 

LOCKE'S  TABLES  OF  FOOD  VALUES 

Through  the  courtesy  of  Dr.  Edwin  A.  Locke  of  Boston,  and  of  D. 
Appleton  and  Company  of  New  York,  we  are  permitted  to  reproduce 
some  of  the  practical  tables  for  use  in  private  practice  and  public 
institutions  as  arranged  by  Dr.  Locke.  These  tables  will  be  found  of 
great  value,  inasmuch  as  the}'  deal  with  the  composition  of  foods  as 
they  are  actually  eaten. 


TABLE  EQUIVALENTS  (APPROXIMATE) 

1  teaspoon    fluid  =      5  c.c.  or  %  fluid  ounce 

1  dessertspoon     fluid  =    10  c.c.  or  ^  fluid  ounce 

1  tablespoon     fluid  =    15  c.c.  or  %  fluid  ounce 

1  ordinary  cup    fluid  ^250  c.c.  or  8      fluid  ounces 

1  tumbler  or  glass   .  .  .  .fluid ^^250  c.c.  or  8      fluid  ounces 

1  cordial  glass  fluid  =    20  c.c.  or  %  fluid  ounce 

1  sherry  glass    fluid  =   30  c.c.  or  1      fluid  ounce 

1  cocktail  glass    fluid  =    75  c.c.  or  2^2  fluid  ounces 

1  claret  glass fluid  =  120  c.c.  or  4      fluid  ounces 

1  champagne  glass  ....  fluid  =  135  c.c.  or  4^2  fluid  ounces 


ABBEEVIATIONS 


a. 

=  average 

a.  h. 

=  average  helping 

c. 

=  cup 

d. 

=  diameter 

dsp. 

=  dessertspoon 

h. 

=  heaping 

m. 

=  medium 

sq. 

=  square 

tbsp. 

^  tablespoon 

tsp. 

=  teaspoon 

851 


852 


FOOD  VALUES 


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APPENDIX 


WAR  DIETING 

The  problem  of  war  dieting  depends  very  largely  upon  the  amount 
and  kind  of  foods  available  and  the  number  of  individuals  to  be  fed. 
As  is  well  known,  in  countries  where  there  has  been  very  great  short- 
age of  the  essential  articles,  regulation  is  done  by  issuing  cards  con- 
taining small  vouchers  for  the  daily  ratiop.  These  must  be  used  upon 
the  day  the  date  of  which  they  bear,  are  not  trausferrable,  and  are 
issued  to  all  entitled  to  them.  The  fighting  army  is  necessarily  the 
first  concern  and  next  to  this  the  infants  and  children,  those  who  are 
to  become  active  belligerents  in  the  future,  and  the  other  members 
of  the  population  in  order  of  their  usefulness. 

It  would  seem  that  the  most  important  consideration  is  the  con- 
servation of  the  animal  fats,  perhaps  with  the  addition  of  those  nut 
oils  containing  vitamins.  Next  to  the  fats  come  the  animal  protein 
foods,  meat,  milk  and  eggs,  next  the  vegetable  proteins,  and  after 
these  the  carbohydrates.  The  problem  in  America  has  been  and  is 
to  feed  the  Allies  and  to  this  end  the  saving  of  the  wheat  and  the 
saving  of  the  meat,  especially  beef,  are  of  primary  importance.  In 
January,  1918,  the  United  States  Food  Administration  issued  a 
home  card  which  contains  the  first  restrictions.  The  suggestions  are 
to  have  two  wheatless  days,  ^Monday  and  Wednesday,  in  every  week, 
and  one  wheatless  meal  in  every  day;  to  have  one  meatless  day, 
Tuesday,  in  every  week  and  one  meatless  meal  in  every  day.  Orig- 
inally two  porkless  days  were  added,  Tuesday  and  Saturday.  In 
addition  to  these  restrictions  for  voluntary  rationing  hotels  and  public 
eating  places  put  a  limit  on  bread,  two  ounces  of  bread  being  allowed 
at  a  meal  or  four  ounces  of  quick  bread,  and  the  amount  of  sugar 
limited  to  each  person.  The  additional  suggestions  were  to  make 
every  day  a  fat-saving  day,  every  day  a  sugar-saving  day,  to  use  fish, 
poultry  and  eggs,  all  perishable  foods,  fruits,  vegetables  and  potatoes 
abundantly.  There  is  a  special  caution  regarding  the  use  of  milk,  us- 
ing whole  milk  for  children,  taking  care  not  to  waste  any  that  is 
left  over,  but  to  use  it  in  cooking  or  making  cottage  cheese.  The  array 
of  the  Allies  is  in  need  of  wheat,  butter,  lard,  sugar,  bacon,  beef,  mut- 
ton and  pork.  Those  remaining  at  home  can  use  in  place  of  wheat, 
corn,  oats,  barley  and  rye,  for  the  fats  the  people  may  substitute  cot- 
tonseed oil,  peanut  oil  and  drippings,  this  last  named  for  cooking. 
In  place  of  sugar,  molasses,  honey,  and  syrups,  and  to  supply  protein 

883 


884  APPEXDIX 

in  place  of  the  more  desirable  meats,  poultry,  eggs,  and  fish,  cheese, 
nuts  and  beans. 

The  eating  habits  of  a  nation  are  not  very  easily  changed  and  all  na- 
tions eat  of  the  food  available,  so  that  changes  are  difficult  to  make, 
first  on  account  of  the  taste,  second,  on  account  of  the  lack  of  informa- 
tion concerning  cooking  and  serving  new  foods.  The  new  dishes 
should  be  as  attractively  arranged  as  possible  and  only  one  added  to 
a  meal  at  a  time,  giving  the  individual  an  opportunity  to  become  ac- 
customed to  the  changes  as  gradually  as  possible.  This  is  not  only 
important  to  keep  the  consumer  from  becoming  tired  of  the  new  dish, 
but  enables  the  body  to  prepare  the  necessary  digestive  juices  in  ease 
there  is  a  change  in  the  composition  of  the  food,  and  prevents  irritat- 
ing diarrhea  in  case  of  use  of  coarser  breads  or  vegetables. 

There  are  a  number  of  rules  given  for  purchasing  food,  perhaps  the 
simplest  ones  are  not  to  save  on  milk,  and  to  spend  at  least  as  much 
for  milk  as  for  meat  and  as  much  for  vegetables  and  fruits  as  for 
meat  and  fish,  and  to  remember  that  cereals  and  bread  stutt's  are 
ordinarily  the  cheapest  foods,  and  the  meats  the  most  expensive  and 
the  animal  fats  the  most  expensive  of  all.  The  fat  allowance  sug- 
gested for  American  people  was  twelve  ounces  a  week  for  each  adult 
and  six  ounces  per  week  for  each  child.  A  suggestion  is  given  to 
substitute  vegetable  fats  wherever  possible.  Animal  fats  should  not, 
however,  be  entirely  excluded  from  the  dietary  as  they  contain  sub- 
stances essential  for  growth  and  health. 

The  suggestion  made  for  saving  wheat  is  to  cut  down  the  use  to 
one-quarter  of  that  formerly  used,  substituting  for  wheat  fiour  the 
flours  made  from  barley,  rice,  potatoes  or  corn  for  one-quarter,  and 
for  the  other  part  the  use  of  potatoes,  either  white  or  sweet,  rice  and 
hominy,  and  other  cereals  can  easily  be  accomplished.  The  saving  of 
meat  is  best  accomplished  by  doing  without  the  meats  essential  for 
the  army,  by  using  "meat  extenders,"  that  is,  using  a  small  amount 
of  meat  to  flavor  a  dish  of  rice  or  hominy  or  other  vegetable,  by  using 
meat  less  frequently,  by  serving  smaller  portions,  and  lastly  by 
substituting  cheese,  eggs,  flsh,  game,  poultry,  and  dried  beans  and 
peas. 

The  saving  of  fats  is  best  accomplished  by  using  butter  as  sparingly 
as  possible,  except  for  children,  and  in  cooking  to  use  some  of  the 
vegetable  oils.  Avoid  the  use  of  pastry  entirely  or  almost  so,  and 
use  vegetable  fats  in  making  them.  The  sugar  saving  is  best  ac- 
complished by  lessening  the  use  of  sugar  in  tea  and  eoft'ee,  omitting 
candy,  cooking  breakfast  cereals  with  chopped  figs,  dates  or  raisins 
and  so  avoiding  the  use  of  sugar  and  substituting  the  use  of  honey, 
molasses  and  other  sweetening.  In  place  of  puddings  or  desserts 
fresh  fruits  or  baked  fruits  should  be  substituted.  Cake  should  be 
given  up  altogether  or  limited  and  the  frosting  made  without  the  use 
of  sugar. 


API'KXDIX  885 

As  to  standards  for  the  civilian  popnlation  in  war-time,  the  low 
protein  limits  of  Chittenden  may  be  used  in  the  lower  caloric  estimates 
for  the  total  ration.  It  should  be  remembered  that  while  the  protein 
in  war  bread  is  nearly  the  same  as  in  ordinarj^  bread,  the  amount 
that  is  available  is  less  and  this  is  also  true  of  certain  other  foods. 
Proper  instruction  in  methods  of  preparing  foods  so  as  to  avoid  waste 
through  cooking  and  through  improper  selection  is  very  impor- 
tant. The  American  people  waste  enormous  amounts  of  food  through 
serving  badly  chosen  and  poorly  balanced  meals.  It  would  be  ex- 
tremely interesting  when  the  war  is  over  to  see  whether  such  diseases 
as  gout  will  have  become  less  frequent  and  also  what  disease  condi- 
tions the  strict  rationing  has  produced.  War  edema  has  been  noted 
elsewhere  in  the  book.  There  is  certainly  less  constipation  and  in 
many  instances  irritating  diarrheal  affections  have  set  up. 

The  National  Food  Administration  has  prepared  a  large  number  of 
recipes  suitable  for  making  dishes  without  the  use  of  the  foods  which 
it  is  necessary  to  save. 

The  dieting  of  prisoners  of  war  in  Germany  has  been  made  the 
subject  of  a  considerable  amount  of  study.  One  article  giving  a  good 
summary  is  by  Taylor  (Journal  of  the  American  Medical  Association, 
November  10,  1917,  p.  1575).  The  rationing  of  the  prisoners  was 
under  a  man  who  was  familiar  with  animal  nutrition,  but  evidently 
not  acquainted  with  modern  investigations  on  growth.  In  some  of 
the  prison  camps  the  fare  was  not  impossible  even  if  scanty,  whereas 
in  others  the  careles.sness  of  preparation  led  to  the  furnishing  of  a 
very  unsatisfactory  diet.  In  order  to  utilize  the  meats  to  the  fullest 
they  were  served  in  the  form  of  soups  which  left  nothing  to  chew  on, 
and  exceedingly  unsatisfactory  when  continued  for  long  periods  of 
time.  Considerable  hardship  also  resulted  from  the  extensive  use  of 
potatoes  in  place  of  bread  and  the  fact  that  the  bread  is  black  sour 
bread,  unpalatable  to  the  French  and  English,  but  apparently  not 
to  the  Russians.  As  Taylor  remarks,  the  feeding  was  done  on  the 
basis  of  the  modern  stock  farm,  and  men  were  dieted  like  domestic 
animals. 

The  following  tables  show  two  weekly  diet  sheets,  one  during  the 
period  before  the  stringency  in  food  stuffs  and  one  after  it  had  started. 

Weekly  Diet  Sheet  Typical  of  Period  Prior  to  f^trinf/ency  in  Foodstuffs.^ 


Bread     ...... 

Gms. 
.  .    2,100 

Oiinces 
75 

0.6 
10.7 
10.7 

.5.3 
.321 
65 
14 

7 

3.5 

1.4 

Sugar      

Legumes 

Fat    

]Maise  grease 
Pearl    Barley 

Dried  fruit    

Marmalade    ...    . 
Tea     

Gms. 

.  .       200 

150 

70 

180 

100 

50 

.  .       100 

16 

Ounces 
7.1 

Flour    ...... 

Meat     

.  .       270 
300 

5.3 
2. .5 

Fish    

300 

6.4 

Herring 

Potatoes     

Vegetables 
ISkim  milk      .  .  . 

1.50 

.  .    0,000 

.       1,800 

400 

.       200 

100 

40 

3..5 
l.S 
3.5 
0  5 

Sausage    

Cheese    

Spices,   herbs    .    . 
Cocoa    

30 
40 

11.1 
1  4 

Nutrient  veast   .  . 

1  Per  diem:  protein,  80  gm.:  fat,  30  gm. ;  carbohydrate,  510  gm.;  calories,  2,740. 


886 


APPENDIX 


Weekly  Diet  Sheet  Typical  of  Period  of  Stringency  in  Foodstuffs.^ 


Gms. 

Bread     2,100 

Flour    50 

Meat     200 

Sausage   200 

Fish    325 

Potatoes     3,500 

Vegetables     1,650 


Skim   milk 

Cheese    

Nutrient  yeast 

Sugar     

Legumes 


500 
100 
20 
130 
150 


Ounces 

75 
1.7 
7 
7 

11 
125 

59 

17 
3.5 
0.7 
4.8 
5.3 


Fat   

Maise  grease    .  .  . 
Pearl  barley  . .  . . 

Fruit    

Marmalade    

Tea   

Coffee     

Chicory    

Cocoa     

Spices  and  herbs 
Mustard     


Gms. 

65 

100 

60 

300 

100 

4 

6 

15 

40 

20 

50 


Ounces 
2.3 
3.5 
2.1 
10.7 
3.5 
0.15 
0.21 
0.5 
1.5 
0.7 
1.7 


iper  diem:  protein,  57  gm.;  fat,  21  gm.;  carbohydrate,  310  gm. ;  calories,  1,720. 


INDEX 


Abscess  of  liver,  diet  in,  499 
Absorbability  in  diets,  practical  value 
of,  39 
of    foods,    Riibner's    table    illustrat- 
ing, 38 
Absorption,  36 
and  digestion,  24 
in  infant  digestion,  36 
in  intestine,  36 
in  liver,  33 
in  mixed  diet,  39 
of  carbohydrates,  38 
of   cereals,   39 
of  fats,  38 
of  fruits,  39 
of  green  vegetables,  39 
of  protein,  38 
of  vegetable  foods,  39 
Acetic  acid,  excretion  of,  in  nephritis, 

540 
Achylia    gastrica,    Einhorn's    diet    in, 
434 
Eisner's  diet  in,  435 
Acid,  acetic,  excretion  of,  in  nephritis, 
540 
benzoic,  as  preservative,  test  for  de- 
tection of,  236 
boric  as  preservative,  232 

test  for  detection  of,  236 
citric,  excretion  of,  in  nephritis,  540 
excess    value    of    foods,    table    from 

Sherman  and  Gettler,  74 
gouty  dyspepsia,  diet   in,   639 
hippuric,   excretion   of,   in   nephritis, 

540 
in  milk,  test  for,  108 
milks  in  infant  feeding,  298 
phosphoric,   excretion   of,    in   nephri- 
tis, 540 
salicylic,  as  preservative,  233 
test  for   detection  of  235 
sulphurous,  as  preservative,  233 
tannic,  178 
uric,  diathesis,  diet  in,  549 

excretion  of,  in  nephritis,  540 
wine,   192 
Acidosis    and    diabetic    coma,    diet    in 
588 
diet  in,  670 

in  acute  nephritis,  diet  in,  538 
in  diabetes,  diet  in,  588 
post-anestlietic,  diet  in,  672 
post-operative,  diet  in,  672 
Acids,   73 

bile,  function  of,  33 
in  wine,  191 

887 


Acidulous  alkaline  waters,  169 
muriated,  170 
saline,  170 
Acne,  diet  in,  681 

rosacea,  diet  in,  681 
Acorn-cocoa,  202 
Acratothermal  waters,   176 
Actinomycosis,  221 

Addis'  test  for  early  diagnosis  of  dia- 
betes  mellitus,  567 
Addison's  disease,  diet  in,  677 
Adulteration,  228 

accidental,  228 

arbitrary,   228 

conventional,  228 

incidental,   228 

intentional,  228 

of  alcoholic  beverages,  229 

of  baking-powder,  231 

of  beer,  229 

of  bread,  230 

of  butter,  231 

of  canned  meat,  232 
vegetables,  232 

of  cider,  230 

of  cocoa,   230 

of  coflee,  230 
test  for,  238 

of  confectionery,   231 

of   cottonseed    oil,    Halphen    reaction 
for  detection  of,  239 

of  flavoring  extracts,  test  for,  238 

of  flour,  230 

of  glycerin,  231 

of  honey,  231 

of  infant  foods,  231 

of  lard,  231 

of  liqueurs,  230 

of  milk,  106 

of  olive  oil,  231 

of  spices,  231 
test  for,  239 

of  tea,  230 

of  vinegar,   test   for,   239 

of  wine,  229 
Agar-agar  crackers,   774 
Age,   relation  of  food  to,  57 
Aged,  diabetes  mellitus  in,  diet,  589 

diet  for,  344 

foods  suitable  for,  345 
Albumin  milk  in  infant  feeding,  298 

water,   769 
Albuminized  jelly,  791 

lemonade,  769 

milk,   781 
Albuminuria,  diet  in,  529 


888 


INDEX 


Albumiuuria,  diet  list  for,  S45 
effect  of  diet  on,  529 
gouty,  diet  in,  639 
Alcohol,  181 

as  circulatory  stimulant,  183 

as  protein  sparer,  18 

as  remedy,  185 

as  respiratory  stimulant,  183 

as  source  of  heat,   182 

of  muscular  energy,   182 
consumption  of,   180 
elfect  of,  on  digestion,  182 

on  gastric  secretion,   184 

on  intellectual  faculties,  185 

on  nervous  system,  183,  184 

on  secretion,  184 

on  woman's  milk,  254 
energy  and  metabolism  of,  181,  182 
excretion  of,  in  nephritis,  541 
food-value  of,   181 
in  angina  pectoris,  519 
in  apoplexy,  556 
in  asthma,  5U6 

in  chronic  interstitial  nephritis,  547 
in  diabetes,  587,  631 
in  diseases  of  liver,  496,  503 

of  nervous  system,  551 
m  eczema,  678,  680 
in  exophthalmic  goiter,  677 
in  fevers,   369 
in  gallstone  diseases,  501 
in  gout,  638 
in  leukemia,  524 
in  pernicious  anemia,  520 
in  pneumonia,  508 

in  alcoholics,  557 

in  children,  509 
in  senile  heart,  515 
in  tuberculosis,   406 
in  Weir-Mitchell  rest  cure,  562 
in  wine,  191 
protection  of  body-fat  by,  181 

of  body-material  by,   182 

of  body-protein,  by,   182 
psychologic  action  of,  185 
use  of  as  food,  185 

in  medicine,  185 
Alcoholic    beverages,    adulteration    of, 

229 
Alcoholics,  illness  or  injury  to,  557 
Alcoholism  as  cause  of  gout,  631 

diet  in,  556 
Aleuronat,  202,  597 
and  almond  cakes,  794 
and  suet  pudding,  794 
bread,  793 
pancakes,  794 
Algse,  147 

Alimentary  alkalis,  157 
glycosuria,  567 

tract,  passage  of  food  through,  24 
Alimentation,  duodenal,  356 


Alkaline  acidulous  waters,  169 
muriated,    170 
saline,  170 
fermentation  of  milk,  101 
mineral  waters,   169 
Alkalis,  73 

alimentary,    157 
in  infant  feeding,  273 
Allantiasis,  217 

Allen's    fasting    treatment    in    diabetes 
mellitus,  575 
treatment  for  diabetes,  576 
fat  tolerance,  576 
Joslin's  modification,  577 
protein  tolerance,   576 
recurrence  of  sugar,  577 
Allergy,  food,  221 

Allies'   army   rations,   comparison,   717 
Alligator  pear,  143 
Almond  and  aleuronat  cakes,  794 
and  cocoanut  cakes,  795 
biscuit,  793 
bitter,  junket,  779 
cakeSj  793 

in  diabetes,  596 
milk,  768 
pudding,  793 
Almonds,   145 
Ambard      test      for      renal      function, 

531 
American  bouillon,  787 
broth,  787 

prisons,  diet  in,  744 
Amino-acids,   64 

passage  of,  through  body,  65 
Amyloid  kidney,  diet  in,  548 

liver,  diet  in,  499 
Amylolytic  enzymes,  27 
Amylopsin  in  infant  digestion,  35 
Amoeba  coli,  210 
Anacid  gastritis,  chronic,  Eisner's  diet 

in,  435 
Anacidity,    nervous,    of    stomach,    diet 

in,  467 
Analyses  of  diabetic  foods,  598 
Anaphylaxis,  food,  221 
Anchylostomum  duodenale,  211 
Anemia,    acute,    posthemorrhagic,    diet 
in,  519 
chronic  secondary,  diet  in,  520 
diet  in,  519 
diet-list  for,  843 
pernicious,  diet  in,  520 
Anesthesia  and  diet,  702 
Aneurysm,  diet  in,  517 
Angina   pectoris,   alcohol   in,   519 

diet  in,  518 
Anilin  dye  in  food,  test  for  detection 

of.  236 
Animal  foods,  93 
viscera,  as  food,  125 

composition  of,  table  showing,  126 
Anorexia,  nervous,  diet  in,  467 


INDEX 


889 


Antifernxentative     diet     in     intestinal 

diseases,  470 
Antiputrefactive      diet      in      intestinal 

diseases,  47t) 
Antiseptics    for    preservation    of    food, 

VJi),  200 
Antitoxin,  effect  of,  on  woman's  milk, 

254 
Apoplexy,  alcohol  in,  556 
comatose  stage,  diet  in,  555 
diet  in,  555 

later  stages,  diet  in,  555 
Apothecaries'  and  metric  measure,  rela- 
tive value  of,  849 
weight,  relative  value  of,  850 
Appendicitis,  diet  in,  484 
Appendix,  883 
Appetite,    influence    of,    on    digestion, 

41 
Apple  snow,  782 

water,  769 
Apples,  143 
Army  rations,  710 

Allies',  comparison,  717 
Filipino,  714 
foreign,  723 
garrison,  713 
haversack,   714 
in  tropics,  719,  720 
travel,  714 
Arnolds   guaiac   method    for   detection 

of  heated  milk,   109 
Aromatic  wine,    192 
Arrowroot  gruel,  771 
Arsenic,    163 

and   iron  waters,    175 
in  food,  234 
Arteriosclerosis   and   diabetes,   diet   in, 
589 
diet  in,  516 
Arthritis  deformans,  diet  in,  640 

rheumatoid,  "diet  in,  640 
Artichoke,  Jerusalem,   139 
Artificial   colors,   determination    of,    in 
food,  236 
food  preparations,  200 

mixed,  202 
infant  feeding,  264 
proprietary   foods,   203 
proteins  made  from  meat,  201 
from  vegetables,  202 
Ascaris  lumbricordes,  211 
Ash,  805 
Asiatic  cholera,  diet  in,  394 

milk  as  cause,  214 
Asparagus,  140 
Asthma,  alcohol  in,  506 

diet  in,  505 
Asylums,  infant  feeding  in,   319 
Athletic    training,    amount    of    protein 
required  in,  250 
diet  during,  243 
relation  of  sugar  to,  245 


Atony  of  large  intestine,  diet  in,  487 
of  stomach,  439 
diet  list  for,  840 

with  hypochlorhydria,  diet  in,  441 
Atrophic  catarrh   of   stomach,  diet   in, 

433 
Atrophy,    acute   yellow,    of    liver,    diet 
in,  499 
in  infant  feeding,  321 
Atwater-Rosa   calorimeter,   45 
Atwater's     table     illustrating     digesti- 
bility   and    fuel-value    of 
foods,  37 
uses  of  food  elements,  43 
of  absorption  in  mixed  diet,   39 
Avocado,  143 

Avoirdupois    and    metric   weight,    rela- 
tive value  of,  850 


Bacillus  cyanogenes  in  milk,  101 
lactic  acid,  in  milk,   104 
lactis  viscosi   in  milk,   101 
prodigiosus  in  milk,  201 
Bacon,    124 

infected,  pneumonia  from,  218 
Bacteria,   effect    of,    on    woman's    milk, 
254 
in  milk,   101 
Bacterial  changes  in  digestion,  33 
Bakers,  naval,   730 
Baking  meat,  206 

Baking-powder,   adulteration  of,   231 
Balfour's  diet  in  senile  heart,  515 
Bananas,  143 
Bauer's    method    of    milk    modification, 

295 
Barley  bread,   133 

extract,   preparation    of,    for    sensiti- 
zation test,  226 
gruel,  771 

with  beef  extract,  789 
jelly,  772 
water,   133,   770 
Barlow's  disease,  diet  in,  665 
Bases,  xanthin,  excretion  of,  in  nephri- 
tis, 540 
Bavarian  cream,  diabetic,  798 
Bay  View  Asylum,  diet  of,  761 
Bean,   soy,    135 

cooking  of,   798 
in  diabetes,  798 
in  infant  feeding,  302 
Beans,    134,    135 

Beaumont's  table  of  chymification,  416 
Beef,    121 

broth  with  grain,   789 

with  poached  eggs,  789 
cuts  of,  805 
essence,  787 

extract,    preparations    of.    for    sensi- 
tization  test,   224 
soup  stock  from,  784 


890 


INDEX 


Beef  extract  with  barley  gruel,  789 
juice,   122,  786 

cold,  786 
peptonized,  787 
preparations,  chemic  composition  of, 

table  showing,   123 
raw,  methods  of  preparing,   788 
soup,  raw,  788 
Beef-extracts,   121 

Beef -products,    composition   of,    122 
Beef -tea,   785,   786 
egg-nog,  789 
flavored,   786 
with  oatmeal,  786 
Beer,  189 

adulteration  of,  229, 
Beet,    139 
Benzoic   acid   as   preservative,   test   for 

detection  of,  236 
Benzoyl-sulphonicimid,     as     substitute 
for  sugar  in  diabetes,  595 
Beriberi,  affinities  and   pathologic   fea- 
tures   of,    table    showing, 
662 
diet  in,   666 
Berries,   143 
Beverages,   167,  768 

in  tuberculosis,  407 
Bickel's  diet-list,  469 
Biedert's  diet  in  dilatation  of  stomach, 
438 
in.   hyperacidity   of   stomach,   472 
Bile,  33 

acids,  function  of,  33 
in  infant  digestion,  35 
Bile-pigments,  function  of,  33 
Bilharzia  htematobia,  210 
Biscuit,  almond,  793 
bran,  774 
inulin,  795 
Jeffries'  gluten,  791 
Bisulphate  of  sodium,  as  preservative, 

233 
Bitter  almond  junket,  779 
milk,  101 
waters,   173 
Bitters,  187 

Black   stools,  in   infant  feeding,   318 
Blackish-brown    stools   in    infant   feed 

ing,  318 
Blanc-mange,  Irish  moss,  791 
Blood-pressure,    high,    diet    in,    517 
Blue  milk,  101 

Boas'  diet  in  atony  of  stomach,  442 
in  carcinoma  of  stomach,  464 
in  chronic  gastritis,  433 

intestinal     catarrh     with     diar- 
rhea, 481 
in  dilatation  of  stomach,  438 
in  diseases  of  stomach,  427 
in  nervous  dyspepsia,   468 
in  ulcer  of  stomach,  447 
oatmeal  test-breakfast,  240 


Boas'  test  for  determining  motor  power 
of  stomach,  240 

test-supper,  240 
Boas-Ewald,  test-breakfast,  239 
Body-fat,  protection  by  alcohol,  181 
Body-material,    protection    by    alcohol, 

182 
Body-protein,     protection     by     alcohol, 

182 
Boiling  meat,   206,   782 
Bone-marrow,    154 
Bonnyclabber,   113 
Borax  as  preservative,  232 
test  for  detection  of,  236 

effect  on   nutrition,   200 
Boric  acid  as  preservative,  232 
test  for  detection   of,  236 
effect  on  nutrition,  200 
Bottle  bouillon,   787 
Botulismus,  217 
Bouillon,   121 

American,  787 

bottle,  787 

cubes,   121 
Bourget's   diet   in   gastric   hemorrhage, 

462 
Bowels,  after  operations,  care  of,  701 

in  diabetes,  589 
Bran  biscuits,  774 

bread  as   substitute  in  diabetes,  596 

cakes,  Camplin's.  792 

muffins   for  constipation,   774 
Brandy,  186 
Brandy-and-egg  mixture,  768 

for  infants,  768 
Brazing  meat,  207 
Bread,   131,  773 

adulteration   of,   230 

aleuronat,  793 

barley,  133 

bran,   as   substitute  in   diabetes,   596 

brown,  773 

diabetic,  792 

Drexel  Institute  recipe,  773 

dried,   198 

gluten,    132 

as  substitute  in  diabetes,  596 

in  tuberculosis,  406 

laxative,  774 

nut-brown,   774 

pulled,  774 

pumpernickel,  132 

rye,   132 

sorghiun,   133 

soy  bean,  801 

substitute  for,  home-made,  796 

torrified  in  diabetes,  596 

wheat,  132 

whole-wheat,  774 
Breakfast  foods,   133 
Breast,  care  of,  in  infant  feeding,  252; 
255 

feeding  for  infants,  251 


INDEX 


891 


Breast-nursing,  directions  for,  261 
Broiling  meat,  207,  783 
Bromin,   lot) 

and  iodin  waters,  171 
Bronchitis,   chronic,   diet   in,   507 

in  obesity,  treatment,  645 
Broth,  American,  787 

beef,  with  grain,  789 
with  poached  eggs,  789 

chicken,   784 

clam,  785 

egg,   768 

meat,   785 

mutton,   with   vegetables,   785 
without  meat,  785 

soy  bean,  799 

veal,  785 

vegetable,  in  infant  feeding,  303 
Brown  bread,  773 

stools  in  infant  feeding,  318 
Brussels   sprouts,   consomme  with,   797 
Buckwheat   flour,    132 
Budin's  rule  for  feeding  premature  in- 
fants,  267^,   269 
Bulkley's    vegetarian     diet     for     carci- 
noma, 674 
Burkart's    diet    in    nervous    dyspepsia, 

467 
Butter,   112 

adulteration  of,  231 

renovated,   112 

testing,  112,  113 
Butterine,  154 
Buttermilk,   113 

and  egg  mixture,  781 

cure,  685 

in   infant   feeding,   297 

Cabbage,  140 
Caflfein,   178,   179 
Caffeol,   179 

Cakes,  aleuronat  and  almond,  794 
almond,   793 
bran,  Camplin's,  792 
cheese,   795 
cocoanut,   795 

and  almond,  795 
Lyster  griddle,  792 
potato  flour,   792 
soy  bean,  800,  801 
nut,   800 
.  thin,  792 
Calcium    and    magnesium    content    of 
vegetable  foods,  527 
metabolism,    163 
and  tetany,   164 
Calcium-containing   foods,    166 
Calculi,  renal,  diet  in,  549 

vesical,  diet  in,  549 
Caloric  content  of  dietary,  scheme  for 
computing,   77 
needs  of  infants,  265 

of  premature  infants,  266 


Caloric  requirements  of  children  at  dif- 
ferent ages,  58 
value  of  foods,   268 

of    modified    milk,    determination, 
267 
Calorie,  definition   of,   44 
Calories  and  percentages,  270 
Calorimeter,   Atwater-Rosa,   45 
bomb,  44 
respiratory,  44 
Calorimetry,   45 
Camplin's  bran  cakes,  792 
Candling,   118 
Candy,  148 

adulteration  of,  231 
Cane-sugar,   148 
Canned   meat,   adulteration   of,   232 

vegetables,  adulteration  of,  232 
Canning  of  food,   199 
Caramel,   148 

in  food,  test  for  detection  of,  237 
Carbohydrate,   amount   required,   68 

requirements  of   infants,  269 
Carbohydrate-cellulose       foods,       table 

showing,  492 
Carbohydrate-free   diet   of   Johns  Hop- 
kins  Hospital,   582-585 
Carbohydrates,  19,  -0,  804 
absorption  of,  38 
concentrated,    198 
equivalents,  629 
foods   rich    in,   accessory   diet   of,   in 

diabetes  mellitus,  573 
in  diseases  of  stomach,  425 
of  vegetables,   129 
Carcinoma,     demineralized     food     and, 
673 
diet  in,  673 

of  stomach,  diet  in,  463 
Care  of  milk,  106 

of  nipples,  in  infant  feeding,  252 
Carrots,  139 

Casein,    cow-,    extract,    preparation   of, 
for       sensitization       test, 
227 
Catarrh,    atrophic,    of    stomach,    diet 
in,  433 
intestinal,  acute,  diet  in,  479 
chronic,  diet  in,  479 

chronic  constipation  in,  diet  in, 
480 
diarrhea  in,  diet  in,  480 
diarrhea     alternating     with 
constipation    in,    diet    in, 
482 
mucomembranous,    of    intestine,   diet 
in,  485 
Catarrhal  jaundice,  diet  in.  497 

in  children,  diet  in,  498 
Caudle,  768 
Cauliflower,  140 
Celery,  140 

soup,  cream  of,  776 


892 


INDEX 


Cellulose,  29 
Cercomonas,  210 
Cereal,  770 
gruels,  770 
portions,   89 

table  showing,  90 
Cereal-and-milk  waters,  781 
Cereals,  130 

chemical  composition  of,  table  show- 
ing, 131 
in  tuberculosis,  406 
length  of  time  to  cook,  771 
Cerebrospinal  fever,  diet  in,  390 
Cheese  cakes,  795 

soy  bean,  800 
Cheese-poisoning,  215 
Chemical     composition      of     American 
food  materials,   802,   810- 
36 
Chestnut  puree,  773 
Chestnuts,   145 

poisoning  from,  219 
Chicken,  124 
broth,  784 
jelly,  789 
Children  at  different  ages,   calorie   re- 
quirements of,  58 
delicate,    nutritive   drink    for,    789 
diabetes  mellitus  in,  diet  in,  589 
diseases  of  heart  in,  diet  in,  513 
food  allowance  for,  58 
pneumonia  in,  alcohol  in,  509 
Children's  Hospital  of  Boston,  diet  of, 

764 
Chlorine-containing  foods,  166 
Chlorosis,  diet  in,  521 
Chocolate,   180 
custard,  782 
Cholelithiasis,  diet  in,  499 

olive  oil  in,  151 
Cholera,  Asiatic,  diet  in,  394 

milk  as  cause,  214 
Cholesterin,  33 
Chorea,  diet  in,  555 
Chorister  boys  in  Saint  Paul's  School, 

Baltimore,   diet   for,   756 
Chymification,    Beaumont's   table,   417 
mean  time  of,  table  showing,   414 
Cider,  196 

adulteration  of,  230 
American,  analysis  of,   195 
Cinnamon-and-milk  drink,   780 
Circulatory    system,    diseases    of,    diet 
in,  510 
diseases  of,  in  obesitv,  treatment, 
644 
stimulant,  alcohol  as,  183 
Cirrhosis  of  liver,  diet  in,  502 
hypertrophic,  diet  in,  502 
with  ascites,  diet  in,  503 
without  ascites,  diet  in,  503 
Citric  acid,   excretion  of,  in  nephritis, 
540 


Clam  broth,  785 

juice,  785 
Clams,  128 

Claret,  consomme  with,  797 
Cleft-palate  operations,  diet  after,  705 
Climate,  relation  of  food  to,  53 
Coagulating  enzymes,  27 
Coal-tar  dyes   in  food,   test  for  detec- 
tion of,  236 
Coccidium   oviforme,   210 
Cocoa,   180 
acorn,  202 
adulteration  of,  230 
cracked,   796 
junket,  778 
Cocoanut,   145 

and  almond  cakes,  795 
cakes,  795 

in  diabetes,  596 
pancakes,  794 
pudding,  795 
Coflfea  arabica,  179 
Coffee,  179 

adulteration  of,  230 

test  for,  238 
composition  of,  180 
intoxication,    chronic,    220 
jelly,  790 
junket,  779 
nutritious,  790 
preparations   of,    179 
Cohnheim's    diet    in    atonic    constipa- 
tion, 493 
in  diarrhea,  488 
in  gastric  cancer,  464 
in  spastic  constipation,  493 
Cold  egg-nog,  768 

process  of  peptonized  milk,  777 
Colic,  gall-stone,  olive  oil  in,  153 

in  infant  feeding,  323 
Colitis,      mucomembranous,      diet      in, 

486 
Color  of  milk,   100 
Coloring-matters  in  food,  228 
Coma,  diabetic,  diet  in,  588 
Commissary,  729,  732 
stewards,  729 

store,  establishment  and  administra- 
tion, 730 
Composition  of  milk,  271 
Concentrated  carbohydrates,   198 
proteins,  198 
vegetables,   198 
Concentration  of  food,   198 
Condensed  milk,   114 

in  infant  feeding,  297 
Condiments,    149 

Confectionery,  adulteration  of,  231 
Confinement,       normal,       diet       after, 

846 
Congestion  of  liver,  diet  in,  498 
Consomme,  797 

with  brussels  sprouts,  797 


INDEX 


893 


Consomme  with  claret,  797 

with  cucumbers,  797 

Constipation  as  cause  of  gout,  631 

bran  mullins  for,  774 

chronic,  diet  in,  480 

diet-list  for,   842 

olive  oil  in,   153 

with  gastric  atony,  diet  in,  441 
habitual,  diet  in,  490 
in  children,  diet  in,  336 
Consumption   of  ak'ohol,    186 
Consumptives,  diet   for,   410 
Convalescence    in    typhoid    fever,    diet 

in,  384 
Cooking  of  fish,  207 
of  foods,  206 
of  meat,  200 
effect  of,  207 
tender.  783 
of  vegetables,  effect  of,  208 
Cooks,  naval,  730 
Copper  in  food,  234 

test  for  detection  of,  237 
Cordial,  egg,  768 
Com,  composition  of,  table  showing,  132 

Indian,    132 
Cornmeal  gruel,   772 

products,       composition      of,       table 
showing,   132 
Cottonseed    oil,    adulteration    of,    Hal- 
phen    reaction    for    detec- 
tion of,   239 
Cow-casein,     extract,     preparation     of, 
for  sensitization  test,  227 
Cow's     milk,     proprietary     foods     pre- 
pared from,  203 
Crab   extract,   preparation   of,   for   sen- 
sitization test,  225 
Cracked  cocoa,  796 
Cracker  gruel,  772 
Crackers,  205 
agar-agar,   774 
crisp,  776 
Craig  Colony  of  epileptics,  dietary  for, 

755 
Cream,  110 

Devonshire,  111 
evaporated,  115 
Cream-of-celery  soup,  776 
Cream-of-potato  soup,  776 
Cream-of-tartar  whey,  779 
Cream-of-tomato  soup,  776 
Creamometer,   107  « 

Creatinin,    excretion    of,    in    nephritis, 

540 
Criminal  lunatic  department  of  prison, 

diet  in,  741 
Crisp  crackers,  776 
Crustaceans,  127 

composition  of,  table  showing,   129 
Crystallose,  595 
Cucumbers,  140 

consomme  with.  797 


Curd  and  whey,  113,  778 
Cure,  buttermilk,  685 

dry,  687 

fruit,    687 

grape,  687 

Kneipp,  688 

kumiss,  685 

meat  and  hot  water,  687 

milk,  683 

Scliroth's,  687 

whey,  685 

yolk,  in  diabetes  mellitus,  686 
Currant  juice,   769 
Currants,   143 
Custard,  baked,  782 

chocolate,   782 

light,   795 

rules    for,    782 

soft,   782 

steamed,  782 
Cuts  of  beef,  805 

of  lamb,  807 

of  meat,  805 

of  mutton.  807 

of  pork.   808 

of  veal,  807 
Cystinuria,  effect  of  diet   on,  529 

Dasheen,   138 

composition  of,   table   showing,    138 
Dates,   143 

Deaminizing  enzymes,  27 
Debility,  diet-lists  for,  843 
Decomposition  in  infant  feeding,  321 
Deficiencv  diseases,  663 

diet 'in,  659 
Deglutition,  24 
Dekofa,  179 

Delirium  tremens,  diet  in,  557 
Delivery  of  milk,  106 
Demineralized  food,   cancer  and,  673 
Deming   milk  modifier,   293 
Dengue,  diet  in,  397 
Desensitization   food,   227 
Devonshire  cream.   111 
Dextrose,    19 
d-Galactose,   21 
d-Glucose,   19 

Diabetes,   diet   in,   567.     See  also  Dia- 
betes Mellitus 
mellitus,     accessory     diet     of     foods 
rich  in  carbohvdrates  for, 
573 
acidosis  in,  diet  in,  588 
alcohol  in,  587 
aleuronat  in,  597 
Allen's  fasting  treatment  in,  575 
treatment,  576 

Joslin's  modification,  577 
almond  cakes  in,  596 
arteriosclerosis  in,  diet  in,  589 
benzoyl-sulphonic-imid,    as    substi- 
tute for  sugar  in,  595 


894 


INDEX 


Diabetes  mellitus,  bowels  in,  589 
bran  bread  in,  596 
cocoanut  cakes  in,  596 
coma  of,  diet  in,  588 
diet  in,  572,  573 
diet-list  for,  844 
dulciu  as  substitute  for  sugar  in, 

596 
early    diagnosis    of,    method    for, 

567 
emergency  diet  in,  587 
exercise  in,  588 
fatal  ratio  in,  570 
fever  in,  diet  in,  589 
garantose  as  substitute  for  sugar 

in,   596 
gluten  bread  in,  596 
glycerin    as    substitute    foi*    sugar 

in,  595 
gout  in,  alcohol  in,  631 

diet  in,  630 
gouty  glycosuria  in,  diet  in,  639 
green  days  diet  in,  585 
in  aged,  diet  in,  589 
in  children,  diet  in,  589 
inulin  biscuits  in,  597 
Johns  Hopkins  green  day  diet  ia- 

586 
milk  in,  796 

nephritis  in,  diet  in,  589 
oatmeal  diet  in,   586 
peanut  flour  in,  597 
prophylactic  diet  in,   570 
recipes  for  food  in,  791 
saccharin  as   substitute  for   sugar 

in,  595 
sasin   as   substitute  for   sugar   in, 

596 
sodium    benzoyl-sulphonic-imid,    as 
substitue     for     sugar     in, 
596 
soups  in,  797 
soy  bean  in,  798 
starch-free  diet  in,  571 
starvation   treatment   of,   diet   fol- 
lowing, 590-595 
substitutes  for  bread  in,  596 

for  sugar  in,  595 
sugar-free  milk  in,  796 
surgical  operations  in,  diet  in,  590 
torrified  bread  in,  596 
vegetable  days  diet  in,  585 
Von  Noorden's  diet  in,  627-629 
yolk  cure  in,  686 
Diabetic,  Bavarian  cream,  798 
bread,  792 
coma,  acidosis  and,  diet  in,  588 

diet  in,  588 
food,  597 
ice  cream,  798 
lemon  jelly,  798 
muffins,  791 
Diabetin,  595 


Diarrhea,  chronic,  diet  in,  480,  488 
diet-list  for,  842 
in  infants,  diet  in,  328 
in  older  children,  diet  in,  332 
simple  acute,  in  infants,  diet  in,  329 
Diarrheal  diseases,  milk  as  cause,  213 
Diathesis,  uric-acid,  diet  in,  549 
Diet,  absorbability  in,  practical  value 
of,  39 
acids,  in,  73 
after  anesthesia,  703 
excision  of  larynx,  705 
laparotomies,   700 
normal  confinement,  846 
operations,  703 

about  gall-bladder,   706 
head,  704 
kidney,  706 
liver,  706 
pancreas,  706 
for  cleft-palate,  705 
for  harelip,  705 
on  esophagus,  705 
on  intestine,  708 
on  stomach,  706 
alkalis  in,  73 
Allen's  treatment  in  diabetes,  576 

Joslin's  modification,   577 
amount  of  fat  and  carbohydrates  re- 
quired  in,   69 
and  anesthesia,  702 
and  laparotomies,  699 
and  teeth,  313 

antifermentative,    in    intestinal    dis- 
eases, 476 
antiputrefactive,     in     intestinal    dis- 
eases, 476 
as  means  of  diagnosis,  239 
at  water  cures,  176 
before  laparotomies.  699 
Biedert's    in    hyperacidity    of    stom- 
ach.'472 
Boas',  in  carcinoma  of  stomach,  464 
in     chronic     catarrh     of     intestine 

with  diarrhea,  481 
in  diseases  of  stomach,  427 
in  nervous  dyspepsia,  468 
Boiirget's  in  gastriv  .hemorrhage,  462 
Burkart's,  in  nervous  dyspepsia,  467 
caloric  content   of,    scheme  for   com- 
puting, 77 
carbohydrate-free,  of   Johns  Hopkins 

Hosp'tal,  582-585 
Cohnheim's  in  gastric  cancer,  464 
cures,  686 

in  diabetes  mellitus,  587 
in  obesity,   647 
diseases  caused  by  errors  in,  209 
during   athletic   training,   243 
Edwards',    in     intestinal    dyspepsia, 

478 
effect   on   albuminuria,   529 
on  cystinuria,  529 


lyDEX 


895 


Diet,  effect  on  development  and  struc- 
ture of  uterus,  350 
on  indicanuria,  529 
on  lipuria,  525 
on  oxaluria,  525 
on  phosphaturia,  525 
Einhoru's,  in  achylia  gastrica,  434 
in  chronic  gastritis,  432 
in    duodenal    feeding,    in    gastric 

ulcer,  461 
in  gastric  ulcer,  447 
in  hyperchlorhydria,  473 
Eisner's,  in  achylia  gastrica,  435 
in  chronic  anacid  gastritis,   435 
errors  in,  diseases  caused  by,  209 
fat-free,  608 
for  aged.  344 
for  boys'  school,  316 
for  child  of  eighteen  to  twenty-four 
months,   309 
fifteen   to   eighteen   months,    308 
twelve  to  fifteen  months,  307,  308 
two  and  one-half  to  six  years,  310 
two    to    two    and    one-half    years, 
309 

articles    forbidden,    311 
for    chorister    boys    in    Saint    Paul's 

School,   Baltimore,   756 
for  consumptives,  410 
for  Government  Hospital  for  Insane, 

St.  Elizabeth,  D.  C,  759 
for  Government  Hospital  for  Insane, 

Washington,  D.  C,  758 
for  insane,  565,  758,  759 
for  leanness,  659 
for  nursing  mother,  252 
for  singers,  242 

for  soldiers  in  tropics,  718-720 
for  speakers,  242 
for  special  conditions,   344 
for    tuberculosis    infirmary,    756 

Metropolitan     Hospital,     Black- 
well's    Island.   756 
green  days,  in  diabetes  mellitus,  585 
hospital,  747 
farinaceous,  748 
light,  747 
meat,  747 
milk,  747 
special,  747 
ward,  747 
in    aberrant    mental    conditions    in 

pregnancy,  350 
in  abscess  of  liver.  499 
in  achylia  gastrica,  434 
in  acid  gouty  dyspepsia,  639 
in  acidosis,  670 

in  acute  nephritis,  538 
in  diabetes,  588 
post-anesthetic,  672 
post-operative,   672 
In  acne,  681 
rosacea,  681 


Diet    in    acute   gastric   indigestion,    in 
children,  326 
gastritis,  429 

in  children,  326 
gout,  635 
heart  disease,  510 
intestinal  catarrh,  479 

obstruction.  484 
nephritis,  541 

due  to  mercuric  chlorid,  545 
posthemorrhagic  anemia,   519 
rheumatism,  393 
yellow  atrophy  of  liver,  499 
in  Addison's  disease,  677 
in    advanced    cases    of    tuberculosis, 

408 
in  alcoholism,  556 
in  amyloid  kidney,  548 

liver,  499 
in  anemia,  519 
in  aneurysm,  517 
in  angina  pectoris,  518 
in  apoplexy.  555 
in  appendicitis,  484 
in  arteriosclerosis,  516 
in  arthritis  deformans,  640 
in  Asiatic  cholera,  394 
in  asthma,  505 

in  atony  of  large  intestine,  487 
of  stomach,  439 

with  hypochlorhydria,   441 
in  atrophic  catarrh  of  stomach,  433 
in  atypical  typhoid,  385 
in  Barlow's  disease,  665 
in  beriberi.  606 
in  bronchitis  in  obesity,  645 
in  carcinoma,  673 
of  stomach.  463 
in  catarrhal  jaundice,  497 

in  children,  498 
in  cerebrospinal   fever,  390 
in  chlorosis,  521 
in   cholelithiasis,  499 
in  chorea,  555 

in  chronic  anacid  gastritis,  435 
bronchitis.  507 
constipation,  480 

witli   gastric   atony.   441 
diarrhea,  480.  488 
gastric     Indigestion,     in     children, 

327 
gastritis,  430 
in  children,  327 
gout,  635 
heart  disease,  510 
ileocolitis  in  children,   333 
interstitial  nephritis.  545 
intestinal  catarrh,  470 
with  diarrhea,  481 
indigestion,     in     children,     333, 

334 
obstruction,  484 
stasis,  493 


896 


INDEX 


Diet  in  chronic  lead  poisoning,  557 
morphin  poisoning,  55t> 
parenchymatous   nephritis,   543 
rheumatism,  31(4 
secondary  anemia,  520 
in  cirrhosis  of  liver,  502 
with  ascites,  503 
without  ascites,  503 
in  complicated  typhoid,  385 
in  congestion  of  liver,  498 
in  constipation  in  children,  336 
in    convalescence    in    typhoid    fever, 

384 
in     cyclic     vomiting,      in     children 

325 
in  deficiency  diseases,  659 
in  delirium  tremens,  557 
in  dengue^  397 
in  diabetes  mellitus,  567 

during  surgical  operations,  590 

emergency,  587 

following    starvation    treatment, 

590-595 
in  aged,  589 
in  children,  589 
prophylactic,   570 
substitutes  for  bread  in,  596 

for  sugar  in,  595 
with  arteriosclerosis,  589 
with  fever,  589 
with  nephritis,  589 
Von  Noorden's,  627-629 
in  diabetic  coma,  588 
in  diarrhea  alternating  with  consti- 
pation   in    chronic    intes- 
tinal catarrh,  482 
in  infants,  328 
in  older  children,  332 
in  digestive  disturbances  in  typhoid 

fever,   383 
in  dilatation  of  stomach,  437 

in  children,  327 
in  disease,  362 

general  rules  for,  362 

of  children,  325 

of  circulatory  system,  510 

of  genito-urinary  system,  525 

of  heart,  510 

in  children,  513 
of  legs  in  obesity,  645 
of  liver,  495 
of  nervous  system,  550 
of  pancreas,  503 
of  respiratory  organs,  504 
of  skin,  678 
of  stomach,  412 

factors  bearing  on,  425 
leguminous.  425 
Leube's,  413 
Penzoldt's,  417,  418 
in  disturbed  sleep,  553 
in  ductless  glands  and  tumors,  676 
in  dysentery,  482 


Diet   in   dyspepsia   and   chronic  enter- 
colitis    due    to     infecting 
protozoa,  483 
in  dysphagia,  429 

in  dyspnea  in  diseases  of  heart,  512 
in  eczema,  679 

in  infants,  680 
in  emphysema,  506 
in  empyema,  504 
in  enuresis  in  children,  341 
in  enteroptosis,  465 
in  epilep'sy,  554 
in  erysipelas,  392 
in  exophthalmic  goiter,  677 
in  fatty  liver,  499 
in  fever,  365 

in  tuberculosis,  411 
in  flatulence,  487 
in  floating  kidney,  548 
in  furunculosis,  682 
in  gall-stone  disease,  499 
in  gastralgia,  552 

in  gastric  disturbances  in  diseases  of 
heart,  512 
special  factors  bearing  on,  425 

irritability    in   tuberculosis,   411 
in  gastroptosis,  465 
in  gingivitis,  in  pregnancy,  349 
in  gonorrhea,  550 
in  gout,  630 
in  goutiness,  630 
in  gouty  albuminuria,  639 

glycosuria  and  diabetes,  639 

obesity,  639,  646 
in   habitual   constipation,   490 
in  Hanot's  disease,  502 
in  headache,  553 
in  hemophilia,  524 
in  hemorrhage  from  lungs,  507 

from  stomach,  461 

in  typhoid  fever,  383 

in  ulcer  of   stomach,   442 
in  hemorrhagic  purpura,  524 
in  hemorrhoids,  487 
in   high   blood-pressure,  517 
in  hyperacidity  of  stomach,  469 
in  hyperchlorhydria,  469 
in  hypersecretion,  435 

of  gastric  juice.  436 
in  hypertrophic  cirrhosis  of  liver,  502 
in   hypertrophy   of   pylorus,   in   chil- 
dren, 328 
in  ileocolitis  in  children,  332 
in  inanition,  in  children,   338 
in  indicanuria,  529 
in  infantile  scurvy,  665 
in  infectious  diseases,  371 
in  influenza,  390 
in  insomnia,  553 

in  intestinal  catarrh,  with  alternat- 
ing diarrhea  and  consti- 
pation, 482 

diseases,  473 


INDEX 


897 


Diet  in  intestinal  dyspepsia,  477 

infantilism,  343 

neurasthenia,  487 
in  intolerance  to  fat,  336 
in  intubation  in  diphtheria,  391 
in   kakke,   GtiG 

in   laryngismus  stridulus,  505 
in  laryngitis,  505 
in  lead  poisoning,  557 
in  leanness,  051) 
in  leukemia,  524 
in  lithemia,  549 

in    lowered    urea    output    in    preg- 
nancy,  349 
in  maidismus,  008 
in  malaria,  397 
in    malignant    growths    of   intestine, 

484 
in  malnutrition,  340 
in  marasmus,  339 
in  measles,  389 
in  meningitis,  390 
in  meteorism,  487 
in  migraine,  553 

in   mucomembranous   catarrh   of   in- 
testine,  485 
in  mumps,  389 
in  navy  hospitals,  752 
in  nephritis,  537,  539 

in  obesity,  645 
in  nephrosis,  544 
in  nervous  anacidity  of  stomach,  467 

anorexia,  467 

diseases,  550 
in  obesity,  646 

disorders  of  intestine,  487 

dyspepsia,  467 

gastric  disorders,   467 

subacidity  of  stomach,  467 

vomiting,  467 
in  neuralgia,  551 
in  obesity,  640,  647,  843 

after   cures   for   pulmonary   tuber- 
culosis, 646 

gout  in,  639,  646 

Oertel's,  653 

skeleton,  652 

starvation,  653 

in  osteomalacia,  677 

in  oxaluria,  525 
in  palpitation,  in  diseases  of  heart, 

512 
in  pancreatic  fistula,  709 
in  pellagra,  668 
in  pelvic  contraction,  Prochownick's, 

348 
in   peptic   ulcer,   during   Sippy   cure, 

456 
in  perforation,  in  typhoid  fever,  383 
in  peritonitis,  494 
in  pernicious  anemia,  520 

vomiting  in  pregnancy,  349 
in  pertussis,  389 


in  phthisis,  408 
in  pleurisy,  504 
in  pneumonia,  507 

in  children,  508 
in  postdiphtheritic  paralysis,  392 
in  pregnancy,  347 

in  obesity,  347 
in  pruritus,  682 
in  psoriasis,  682 
in  public  institutions,  734 
in  puerperium,  349 
in  purpura  haemorrhagica,  524 
in  pyelitis,  549 
in  pyelonephritis,  549 
in  pylorospasm  in  children,  328 
in  rabies,  399 
in  rachitis,  341 
in  renal  calculi,  549 
in  rheumatism,  393 
in  rheumatoid  arthritis,  640 
in  rickets,  341 

in  salivation  in  pregnancy,  349 
in  scarlet  fever,  387 
in  scorbutus,  664 
in  scurvy,  664 

in  adults,  664 

infantile,  665 
in  shock  after  operations,  702 
in  skin  diseases,  678 
in  simple  acute  diarrhea,  in  infants, 

329 
in  small-pox,  386 

in  special  diseases  of  pregnancy,  349 
in  sprue,  398 

in  stomatitis,  in  children,  326 
in    surgical    operations    in    diabetes, 

590 
in  syphilis  of  liver,  499 
in  tetanus,  398 

in  thirst  after  operations,  701 
in  toxic  conditions,  556 
in  tuberculosis,  399 
in  typhoid  fever,  371 
in  typhus  fever,  386 
in  tumors  and  ductless  glands,  676 
in  ulcer  of  duodenum,  483 

of  intestine,  483 

of  stomach,  442 
in  uric-acid  diathesis,  549 
in  urticaria,  681 
in  vertigo,  554 
in  vesical  calculi.  549 
in  visceral  neuralgia,  552 
in  war,  883 

in  whooping-cough,  389 
in  yellow  fever,  396 
Johns   Hopkins  Hospital   green  day, 
in  diabetes  mellitus,  586 
low  protein,  537 
oatmeal  day,  in  diabetes  mel- 
litus, 586 
Joslin's  modification  of  Allen's  treat- 
ment in  diabetes,  577 


898 


INDEX 


Diet,  Joslin's  strict   diet-lists   for   dia- 
betes meliitus,  578-582 
Karell,  683 
leguminous    in   diseases    of   stomach, 

425 
Lenhartz,    in    ulcer    of    stomach,   au- 
thor's   modification,    451 
Lambert  modification,  449 
Scale  Harris  moditication,  450 
Leube's    diet    scale    in    diseases    of 

stomach,  413 
liquid  in  gastric  disorders,  422 
mixed,  absorption  in,  39 
oatmeal,       in       diabetes       meliitus, 

586 
Ochsner's,  in  peritonitis,  494 
Oertel's   in   circulatory  disturbances, 

and  obesity,  657 
Oertel's,  in  obesity,  653 
of  Bay  View  Asylum,  761 
of    Children's    Hospital    of     Boston, 

764 
of  Craig  Epileptic  colony,  755 
of  Great  Ormond  Street  Hospital  for 
Sick      Children,      London, 
766 
of  Johns  Hopkins  Hospital,  748 
of      Lakeside     Hospital,      Cleveland, 

Ohio,  749 
of  Robert  Garrett  Free  Hospital  for 
Children,    Baltimore,    763 
of  school  children,  314 
of    Second    Hospital    for    Insane    of 

Maryland,  757 
of  United   States   Marine   Hospitals, 

754 
Penzoldt's    in    diseases    of    stomach, 

418 
planning,  71 
prescribing  of,  76 
prison,  735 
American,  744 
Dunlop's,  737 
English,  744 
French,   746 
in    criminal    lunatic    department, 

741 
ordinary,  745 
Prussian,  747 
Prochownick's      in      pelvic     contrac- 
tions, 348 
prophylactic  in  diabetes,  570 
protein,  high,  63 
low,  62 

objections  to,  63 
value  of,  63 
optimum,  64 
raw  eggs  in,  119 

Eiibner's,  in  intestinal  diseases,   474 
salt-free,  688 
Sippy's   modified,    in    mild    cases    of 

peptic  ulcer,  458 
skeleton,  ia  obesity,  652 


Diet,     Smithies',     in     dyspepsia     and 
chronic    interocolitis    due 
to  infecting  protozoa,  483 
in  ulcer,  459 
starvation,  in  obesity,  653 
Strauss'  in  enteroptosis,  466 
variety  in,  efi'ect  on  digestion,  41 
various  factors   in  their  bearing  on, 

198 
vegetable  days  in  diabetes,  585 
disadvantages  of,   141 
for  carcinoma,  674 
vitamins  in,  72 

Von   Noorden's   green   days,    in    dia- 
betes, 585 
in  chlorosis,  523 
in  diabetes,  627-629 
in  diseases  of  stomach,  423 
oatmeal,  in  diabetes,  586 
Wegele's,   in  atony  of  stomach  with 
hyperchlorhydria,    441 
in    atrophic    catarrh    of    stomach, 

434 
in  carcinoma  of  stomach,  464 
in  chronic  constipation,  491 

diarrhea,  489 
in  dilatation  of  stomach,  438 
in  hemorrhoids,  488 
in  hyperacidity  of  stomach,  473 
in  hypersecretion,  436 
in  ulcer  of  stomach,  445 
Weir-Mitchell  rest  cure,  557 
Zweig's,  in  achylia  gastrica,  435 
in  chronic  intestinal  catarrh  with 
constipation,  480 
with  diarrhea,  481 
in  dilatation  of  stomach  with  an- 

acidity,  439 
in  enteroptosis,  466 
in  gastric   carcinoma,   464 
in  mucomembranous  colitis,  486 
Dietaries  in  public  institutions,  734 
Dietary  standards,  69 
Dietetic  errors  in  infant  feeding,  symp- 
toms, 319 
management  of  shock,  702 

of  surgical  cases,  699 
test   in   diagnosis   of   ulcer   of   stom- 
ach, 244 
for    determining    motor    power    of 
stomach,  240 
at    same    time    disturbances    of 
motor  and  secretory  func- 
tions of  stomach,  241 
treatment  of  hemorrhoids,  487 

of  nervous   affections   of  intestine, 
487 
Dieting,  war,  883 
Diet-lists,  rapid  reference,  837 
Digestibility   of   food,   Penzoldt's   table 
showing,  417 
of  meats,  120 
of  vegetable  fats,  39 


INDEX 


899 


Digestibility  of  vegetables,  130 
Digestion  and  absorption,  24 

bacterial  changes  in,  33 

chemistry  and  physiology  of,   17 

effect  of  alcohol  on,  18^1 

enzymes    concerned    in    processes    of, 
table  showing,  28 

gastric,  29 

in  infants,   peculiarities  of,   34 

inliuence  of  various  factors  upon,  40 

intestinal,  31 

of  milk,  100 

passage  of   food   through   alimentary 
tract,  24 

salivary,  29 

tobacco  affecting,  35 
Digestive      disturbances      in      typhoid 

fever,  diet  in,  383 
Dilatation  of  stomach,  diet  in,  437 
diet-list  for,  839 
in  children,  diet  in,  327 

sudden,  in  diseases  of  heart,  diet  in, 
512 
Diphtheria,  diet  in,  391 

intubation  in,  diet  in,  391 

milk  as  cause,  214 
Disaccharids,  21 

Disease,  food  requirements  in,  53 
Distoma  hepaticum,  210 
Dracunculus  medinensis,  211 
Drexel   Institute  recipe  for   bread,   773 
Drop  method  for  administration  of  nu- 
trient enema,   355 
Drugs,  effect  of,  on  woman's  milk,  254 
Dry  cure,  687 
Duck,   124 

Ductless  glands,  tumors,  diet  and,  676 
Dulcin  as  substitute  for  sugar  in  dia- 
betes, 596 
Dunlop's  prison  diet,  737 
Duodenal  alimentation,  356 

Einhorn's  diet  in.  461 
Duodenum,  stenosis  of,  olive  oil  in,  152 

ulcer  of,  diet  in,  483 
Dysentery,  chronic,  oliAe  oil  in,   152 

diet  in,  482 
Dyspepsia,  acid  goutv,  diet  in,  639 
'diet-list  for,   839 

in  infant  feeding,  321 

intestinal,  diet  in,  477 

nervous,  diet  in,  467 
Dyspeptics,  jelly  for,  789 
D\'sphagia,  diet  in,  429 
Dyspnea,  in  diseases  of  heart,  diet  in, 
512 


Earthy  mineral  waters,  175 
Eczema,  diet  in,  679 

in  infants,  diet  in,  680 
Edema  in  diseases  of  heart,  diet  in.  512 
Education  of  mother  in  infant  feeding, 
251,  261 


Edwards'  diet  in  intestinal  dyspepsia, 

478 
Effervescent  peptonized  milk,  777 
Effervescing  lemonade,  769 
Egg  and  buttermilk  mixture,  781 
and  grape  juice,   770 
broth,  768 
cordial,  768 
gruel,  788 
pudding,  782 
white    extract,    preparation    of,    for 

sensitization  test,   227 
with  junket,  778 
Egg-and-brandy  mixture,  768 

for  infants,  768 
Egg-nog,    119 
beef-tea,  789 
cold,  768 
hot,  768 
Eggplant,  140 
Eggs,  117,  781 
absorption  of,  38 
age  of,  method  of  testing,  119 
and  milk,  782 

composition  of,   table   showing,    118 
decomposition   of,   prevention,   120 
digestibility   of,   table   showing,    119 
flavor  of,  118 

freshness   of,  method  of  testing,    118 
hard-cooked,   781 
in  diseases  of  stomach,  424 
in  tuberculosis,  404 
in  typhoid  fever,  376 
poached,  with  beef  broth,  789 
raw,  in  diet,  119 
soft-cooked,  781 
Einhorn's  diet  in  achylia  gastrica,  434 
in  chronic  gastritis,  432 
in  gastric  ulcer,  447 
in  hyperchlorhydria,  473 
method     of     duodenal     alimentation, 
356,  357 
in  gastric  ulcer,  461 
Eiweiss  milch,  298 
Eisner's  diet   in  achylia  gastrica,  435 

diet  in  chronic  anacid  gastritis,  435 
Emotion,  effect  on  digestion,  42 
Emphysema,  diet  in,  506 
Empyema,  diet  in,   504 
Emulsion   of  sweet-almond  oil,   in  gas- 
tric disorders,   153 
Enema,  nutrient,   351 

by  drop  method,  355 
indications  for  use  of,  355 
method  of  giving,  353 
prevention  of  parotitis  during,  355 
Energy  and  metabolism  of  alcohol,  181, 

182 
Energy-value  of  food,  46 
English  prison  diet,   744 
Enterokinase,  32 
Enteroptosis,  diet  in,  465 
Enuresis  in  children,  diet  in,  341 


900 


INDEX 


Enzymes,  26 

activity  of,  28 

amyolytic,  27 

coagulating,  27 

concerned  in  processes  of  digestion 
and  nutrition,  table  show- 
ing, 28 

deaminizing,  27 

fat-splitting,  27 

lipolytic,  27 

oxidizing,   27 

properties  of,  28 

protective,   27 

protein-splitting,  26 

proteolytic,  26 

starch-splitting,  27 

sugar-splitting,  27 
Epilepsy,  diet  in,  554 

diet-l'ist  for,  846 
Erepsin,  32 

in  infant  digestion,  35 
Ergotism,  219 
Erysipelas,  diet  in,  392 
Esophageal  operations,  diet  after,  705 
Esophagus,    stricture    of,    olive    oil    in, 

151 
Essence  of  beef,  787 
Ethers  in  wine,  191 
Eucasein,  201 
Ewald  and  Boas,  test-breakfast  of,  239 

diet  in  chronic  gastritis,  431 
in  membranous  colitis,  486 
Excision  of  larnyx,  diet  after,  705 
Exercise    and    rest,    before    and    after 
meals,  influence  of,  on  di- 
gestion, 42 

in  diabetes,  588 
Exophthalmic  goiter,  diet  in,  677 
Extractives,  in  vegetables,  130 

in  wine,  191 
Extracts,     flavoring,     adulteration     of, 
test  for,  238 


Facing  tea  leaves,  230 
Farina  gruel,  771 

Farinaceous  foods  in  which  starch  has 

not  been  predigested,  204 

prepared    from    cereals    of    which 

starch  has  been  converted 

into  dextrin  or  sugar,  204 

Fast  cure  in  diseases  of  stomach.  429 

Fasting  treatment,  Allen's,  in  diabetes 

mellitus,  575 
Fat,  150,  804 

absorption  of,  38 
amount  required,  68 
and  allied  substances,  23 
in  diseases  of  stomach,  425 
in  milk,  273 

tests  for,  107 
in  tuberculosis,  406 


Fat,  in  vegetables,  130 

intolerance    to,    infant    feeding    in, 
336 

metabolism,  23 

requirements  of  infant,  269 

vegetable,  digestibility  of,  39 
Fat-free  diet,  698 
Fat-splitting  enzymes,  27 
Fatty  foods,  indications  for  use  of,  150 

liver,  diet  in,  499 

oils,  23 
Feces,  mineral  matter  in,  154 
Feeding,  forced,  697 

infant,  251.     See  also  Infant  feeding. 

special  methods  of,  351 
Fermentation,  alkaline,  of  milk,  101 
Ferments,  effect  of,   on  woman's  milk, 
254  ^ 

in  milk,  96--     ' 
Ferson,  202 
Fever,  alcohol  in,  369 

cerebrospinal,  diet  in,  390 

diet-list  for,  839 

effect  on  metabolism,  53 

feeding  in,  365 

in  diabetes,  diet  in,  589 

in  tuberculosis,  diet  in,  411 

scarlet,  diet   in,  387 

typhoid,  diet  in,  371 

typhus,  diet  in,  386 

yellow,  diet  in,  396 
Figs,  143 
Filaria,  211 

sanguinis  hominis,  211 
Filipino  ration,   714 
Finkelstein's     classification     in    infant 

feeding,    320 
Finney  and  Friedenwald's  diet  follow- 
ing   operations    on    stom- 
ach, 708 
Fish,   126 

absorption  of,  38 

composition   of,   table   showing,    127, 
128 

cooking  of,  207 

extract,   preparation   of,   for   sensiti- 
zation test,  225 

in  tuberculosis,  406 

poisoning  from,  216 
Fistula,  gastric,  feeding  through,  709 

intestinal,   feeding  through,   709 

pancreatic,  diet  in,  709 
Flatulence,  diet  in,  487 

in  diseases  of  heart,  diet  in,  512 
Flavoring     extracts,     adulteration     of, 

test  for,  238 
Flavors  in  milk,  101 
Flaxseed  tea,  769 

Fleischer's  table  for  showing  power  of 
foods     to     combine     with 
HCL,  470 
Fletcherism,  688 
Floating  kidney,  diet  in,  548 


INDEX 


901 


Flour,  131 

adulteration  of,  230 
ball,  772 

gruel,  772 
buckwheat,  132 
gruel,  771 
peanut,  796 

in  diabetes,  597 
Fluid   intake  and   renal  function,  538 
Food,  absorption  of,  36 
table  showing,  38 
adulteration,    228.     See    also    Adul- 
teration. 
alcohol  as,  185 
allergy,  221 

allowances  for  children,  58 
anaphylaxis,  221 

and  emotion,   iniluence  of,  on  diges- 
tion, 42 
animal,  93 

viscera  as,   125 
arsenic  in,  234 
artificial  colors  in,  determination  of, 

236 
breakfast,   133 

borax  in,  as  preservative,  232 
test  for  detection  of,  236 
boric  acid  in,  as  preservative,  232 

test  for  detection  of,  236 
calcium-coiitaiuing,   166 
caloric  value  of,   268 

per  ounce,  92 
caramel     in    test    for    detection    of, 

237 
carbohydrate-cellulose,    Krause-Garre 

table  showing,  492 
chlorine-containing,    166 
classes  of,  93 
coal-tar   d\es    in,    test    for    detection 

"of,  236 
coloring-matter  in.  228 
composition  of.  46 

table  showing,  420 
concentration  of,  198 
cooking  of,  206 
copper  in,  234 

test  for  detection  of,  237 
demineralized,  cancer  and,  673 
desensitization,  227 
diabetic,  597 
analysis  of,  598 
■  digestibility      of,      Penzoldt's      table 
showing,  417 
economics,  69 

elements,    Atwater's    table    illustrat- 
ing digestibility  and  fuel- 
value  of.  37 
uses  of,  43 
Riibner's     table     illustrating,     ab- 
sorbability of,  38 
energy-value  of,  46 
farinaceous,  in  which  starch  has  not 
been  predigested,  204 


Food,    farinaceous,    prepared    from    ce- 
reals of  which  starch  has 
been    converted   into    dex- 
trin or  sugar,  204 
fatty,  indications  for  use  of,   150 
for  diabetes,  recipes  for,  791 
formaldehyde     as     preservative     in, 
233 
test  for  detection  of,  236 
fuel    value,    method    of  determining, 

44,  48 
gelatinous   forms   of   in   gastric   dis- 
orders, 424 
heat-value  of,  47 

method  of  determining,  44,  48 
hypersusceptibility,    222 
idiosyncrasy,  221 
infant,  adulteration  of,  231 
iron-containing,  105 
lead  in,  234 

liquid,  ideal  ration  of,  90 
in  gastric  disorders,  422 
magnesium   and   calcium   content   of, 

527 
magnesium-containing,    166 
materials,    American,    chemical   com- 
position   of,    tables    show- 
ing,  802,   810-36 
composition  of,  803 
metallic  poisons  in,  234 
nickel  in,  234 
nutritive  ratio.  49 
oxalic-acid  content  of,  527 
parasites  in,  diseases  caused  by,  210 
passage      of,      through      alimentary 

tract,  24 
percentage       of       salt       foundation, 
Zweig's     tables     showing, 
471 
phosphorus-containing,   165 
potassium-containing,    165 
preparations,   artificial.   200 

mixed.  202 
preservation  of,   198.     See  also  Pres- 
ervation of  food. 
preservatives  in,  232.     See  also  Pre- 
servatives. 
proprietary  artificial,  203 

prepared   from   cow's  milk.  203 
proteins,  superior  and  inferior,  19 
purin  bodies  in,  633 
relation  of,  to  age,  57 
to  climate,  53 
to  race.  54 
to  sex,  55 

to  size  and  weight,  55 
to  skin  surface,  55 
urine  to,  525 
requirements  in  disease,  53 

total,  49 
rich  in  carbohydrates,  accessory  diet 
of,    in    diabetes    mellitus, 
573 


902 


INDEX 


Food,  salt  content  of,  691 
table  showing,   156 
scale,  75 

Hart's,  75 
sensitization,   221.     See  also  Sensiti- 
zation, food. 
sodium-containing,    165 
suitable  for  aged,  345 
sulphur-containing,   166 
suppositories,  358 

temperature  of,   influence   of,   on   di- 
gestion, 42 
tolerance  for,  in  infant  feeding,  270 
turmeric    in,    test    for    detection    of, 

237 
values  of,  in  household  measures,  91 

Locke's  tables  of,  851 
vegetable,  129 

absorption  of,  39 
classification,  130 
weight  and  caloric  value  of  standard 
portion,      table      showing, 
84-89 
zinc  in,  234 
Food-consumption    in    training    camps, 
statistical   report,   716 
of  persons  in  different  circumstances, 
table  showing,  51 
Food-poisoning,  acute,  210 
Food-poisons,  diseases  caused  by,  209 
Food-value  of  alcohol,  181 

per  pound  of  nutrients  in  food  ma- 
terials, table  showing,   37 
Foot-and-mouth  disease,  221 
Forced  feeding,  607 

in  diseases  of  stomach,  428 
in  tuberculosis,  412 
Foreign  army  rations,  723 
Formaldehyd   as   preservative.  233 
test  for  detection  of,  236 
in  milk,  detection  of,   109 
Hehner's  test  for,   109 
Leach's   test  for,   109 
Fortified  wine,  191,  196 
Fowl,  124 

Fraley's  method  for  estimating  caloric 
value  of  infant's  food,  267 
French  prison  diet,  746 
Friedenwald  and   Finney's  diet  follow- 
ing   operations    on    stom- 
ach, 708 
Frost  and  Ravenel  microscopic  test  for 
detection   of  heated  milk. 
110 
Frozen  milk,  97 
Fructose,  19 
Fruit  cures,  687 

in  tuberculosis,  406 
Fruits,  142 

absorption  of,  39 

composition  of,  table  showing,  144 

digestibility  of,  142 

in  diseases  of  stomach,  425 


Fruit-sugar,   149,  595 
Frying  meat,  207 
Fuel-value,  805 

of  food,  method  of  determining,  44, 
48 
Fungi,  146 
Furunculosis,  diet  in,  682 


Gaxactogen,  201 

Galactogogues,  253 

Galactotoxismus,   214 

Gall-bladder,     operations     about,     diet 

after,  706 
Gall-stone  colic,  olive  oil  in,  153 

disease,  diet  in,  499 
Game,   124 
Garantose,  as  substitute  for  sugar   in 

diabetes,  596 
Garlic,  141 
Garrison  rations,  713 
Gastric  disorders,  liquid  foods  in,  422 
disturbances    in    diseases    of    heart, 

diet  in.  512 
indigestion,   acute,    in   children,   diet 
in,  326 
chronic,  in  children,  diet  in,  327 
irritabilitv   in   tuberculosis,   diet   in, 

'  411 
juice,  30 

hypersecretion  of,  diet  in,  436 
neurosis,  olive  oil  in,  152 
secretin,  30 
Gastritis,  acute,  diet  in,  429 
in  children,  diet  in,  326 
anacid,  chronic,  Eisner's  diet  in,  435 
chronic,  diet  in,  430 
diet-list  for,  839 
in  children,  diet  in,  327 
Gastralgia,  diet  in,  552 
Gastrectasia,  olive  oil  in,   152 
Gastroptosis,  diet  in,  465 
Gavage  in  diseases  of  stomach,  428 

in  infant  feeding,  324 
Geese,  124 

Gelatin,  dishes  made  with,  790 
in  infant  feeding,  301 
meat  jelly  with.  791 
without,   789 
Genitourinary     system,      diseases  '  of, 

diet  in,  525 
Germain  See,  test-meal  of,  240 
Gin,  187 

Gingivitis  in  pregnancy,  diet  in,  349 
Gluten  bread,   132 

as  substitute  in  diabetes,  596 
biscuit,  Jeffries',  791 
gruel,  772 
pancakes,  791 
pudding,  791 
Glucose,  149 

tolerance,  21 
Glucosides,  21 


INDEX 


903 


Glycerin,  23,  595 
adulteration  of,  231 
as  substitute  for  sugar  in  diabetes, 

595 
in  wine,  191 
Glycerol,  23 
Glycogen,  22 
Glycogenase,  22 
Glycosuria,   alimentary,   567 

gouty  and  diabetes,  diet  in,  639 
renal,  569 
Goiter,  exophthalmic,  diet  in,  677 
Gonorrhea,  diet  in,  550 
Gooseberries,  143 
Gout,  acute,  diet  in,  635 
alcohol  in,  638 
alcoholism  as  cause,  631 
chronic,  diet  in,  635 
constipation  as  cause,  631 
diet  in,  630 
diet-list  for,  844 
heredity  as  cause,  631 
in  lead  workers,  631 
in  obesity,  diet  in,  646 
indigestion  as  cause,  631 ' 
mental  work  as  cause,  631 
mineral  waters  in,  637 
overeating  as  cause,  631 
saline  springs  in,  657 
treatment  of,  preventive,  635 
Goutiness,  diet  in,  630 

diet-list  for,  844 
Gouty  albuminuria,  diet  in,  639 
dyspepsia,  acid,  diet  in,  639 
glycosuria  and  diabetes,  diet  in,  639 
obesity,  diet  in,  639 
Government    Hospital    for    Insane,    St. 
Elizabeth,  D.  C,  diet  for, 
759 
Washington,  D.  C,  diet  for,  758 
Grain-poisoning,  219 
Grape  cure,  687 

in  diseases  of  stomach,  428 
juice,  770 
and  egg,  770 
whey,  779 
Grapes,  143 
Grape-sugar,   19,  149 
Great     Ormond     Street     Hospital     for 
Sick      Children,      London, 
diet  of,  766 
Green    dav   diet    in    diabetes    mellitus, 
585 
of   Johns   Hopkins   Hospital   for 
diabetes   mellitus,   586 
Green  gages,  143 

stools  in  infant  feeding,  318 
vegetables,  139 
absorption  of,  39 

composition  of,  table  showing,  141 
digestibility  of.   139 
Growth  and  nutrition,  59 
Gruel,  arrowroot,  771 


Gruel,  barley,  771 

with  beef  extract,  789 

cereal,  770 

cornmeal,  772 

cracker,  772 

egg,  788 

farina,  771 

flour,  771 

flour-ball,   772 

gluten,  772 

Imperial  Granum,  772 

malted,  in  infant  feeding,  305 

oatmeal,  771 

peptonized   milk,   778 

soy  bean,  799 

standardized,  in  infant  feeding,  301 
Guinea-worm,  211 

Halogens,  158 

Halphen  reaction  for  detection  of  adul- 
teration of  cottonseed  oil, 
239 
Ham,  124 

Hanot's  disease,  diet  in,  502 
Hard-cooked  eggs,  781 
Hard-tack,   198 

Harelip,  operations,  diet  after,  705 
Hausmann,    starch    retention    test    of, 

240 
Haversack  rations,  714 
Head,  operations  about,  diet  after,  704 
Headache,  diet  in,  553 
Heart,   diseases   of,  diet  in,   510 
dyspnea  in,  diet  in,  512 
edema  in,  diet  in,  512 
flatulence  in,  diet  in,  512 
gastric    disturbances    in,    diet    in, 

512 
in  children,  diet  in,  513 
palpitation  of,  diet  In,  512 
sudden  dilatation   in,  diet  in,  512 
senile,  alcohol  in,  515 
diet  in,  513 
Heat,  action  of,  on  milk,  96 
alcohol  as  source  of,  182 
effect  on  metabolism,  53 
Heated  milk,  detection  of,  109 

Arnold's  guaiac  method,   109 
Frost    and    Ravenel    microscopic 

test  for,   110 
Storch's  method,  109 
Heat-value  of  food,  46 
Hehner's   test  for  detection  of  formal- 

dehyd  in  milk,   109 
Height    and    weight    at   different   ages, 

tables  for,  649 
Hemophilia,  diet  in,  524 
Hemorrhage  from  lungs,  diet  in,  507 
from  stomach,  diet  in,  461 
gelatin  in,  462 
hot-water  enema  in,  462 
salt  solution  in,  462 
in  typhoid  fever,  diet  in,  383 


904 


INDEX 


Hemorrhage  in  ulcer  of  stomach,  diet 

in,  442 
Hemorrhagic  purpura,  diet  in,  524 
Hemorrhoids,     dietetic     treatment     of, 

487 
Heredity  as  cause  of  gout,  631 
Hippuric  acid,  excretion  of  in  nephri- 
tis, 540 
Hollandaise  sauce,  797 
Holt's  percentage  milk  method,  287 
Homogenized    oil    mixture    in    infant 

feeding,  304 
Honey,  149 

adulteration  of,  231 
Horse  meat,  124 
Horseradish,  150 
Hospital  diet,   747 
farinaceous,   748 
light,  747 
meat,  747 
milk,  747 
special,  747 
ward,  747 
marine,  diet  in,  754 
navy,  diet  in,  752 
Hot  egg-nog,  768 

peptonized  milk,  777 
water  and  meat  cure,  687 
Huckleberries,  143 
Hydatid  disease,  221 
Hydrocarbon,   15U,  804.     See  also  Fat. 
Hydrogen  peroxid,  as  preservative,  234 

in  milk,  detection  of,   109 
Hydrogenation  of  oils,   150 
Hygiama,  202 
Hyperacidity,  diet-list  for,  840 

of  stomach,  diet  in,  469 
Hyperchlorhydria,  diet  in,  469 
diet-list  for,  840 

with  atony  of  stomach,  diet  in,  441 
Hypersecretion,  chronic,  diet  in,  435 
diet  in,  435 

intermittent,  diet  in,  435 
of  gastric  juice,  diet  in,  436 
Hypersusceptibility,   food,   222 
Hypertrophic    cirrhosis    of    liver,    diet 

in,  502 
Hypertrophy    of    pylorus,    in    children, 
diet  in,  328 

Ice  Cream,  diabetic,  798 
Iced  meat  extract,  786 
Iceland  moss,  147 
Ichthyotoxismus,  216 
Idiosyncrasy,  food,  221 
Ileocolitis,  chronic,  in  children,  diet  in, 
333 

in  children,  diet  in,  332 
Imperial  drink,  769 

granum  gruel,  772 
Inanition  in  children,  diet  in,  338 

infant  feeding  in,  338 
Indian  corn,  132 
Indicanuria,  effect  of  diet  on,  529 


Indifferent  waters,  176 
Indigestion,  acute  gastric,  in  children, 
diet  in,  326 
as  cause  of  gout,  631 
chronic  gastric,  in  children,  diet  in, 
327 
intestinal,  in  children,  diet  in,  333, 
334 
Infant,     brandy-and-egg    mixture    for, 
768 
caloric  needs  of,  265 
digestion,  absorption  in,  36 
peculiarities  of,  34 
secretions  in,  35 
stomach  in,  34 
eczema  in,  diet  in,  680 
feeding,  251 

acid  milks  in,  298 
albumin-milk  in,  298 
alkalis  in,  273 
artificial,  264 

problem  of,  265 
atrophy  in,  321 

beginning    cases    that    have    been 
previously  improperly 

fed,  317 
bottle,  beginning,  278 
breast,  251 

conditions      affecting      woman's 

milk,  254 
contraindications  to,  251,  261 
care  of  breasts  in,  255 

of  nipples,  252 
education  of  mother,  251 
first  few  days,  258 
galactogogues   in,   253 
if  child  is  not  getting  sufficient 

food,  259 
importance  of  emptying  breasts, 

258 
intervals  for,  255 
mental   attitude  of   mother,   260 
mixed,  257 
modifying   milk,   256 
nursing  mother,  252 
reestablishment  of  lactation,  253 
testing  milk,  256 
weaning.  262 
wet-nursing,   262 
buttermilk  in,  297 
carboliydrate  requirements  of,  269 
colic  in,  323 

condensed  milk  in,   115,  297 
decomposition  in,  321 
dietetic  errors  in,  symptoms,  319 
disturbed     metabolic     balance    in, 

320 
during  second  year,  306 
dyspepsia  in,  321 
fat  indigestion  in,  281 
requirements  of,  269 
Finkelstein's  classification,  320 
gavage  in,  324 
gelatin  in,  301 


INDEX 


905 


Infant  feeding,  Holt's  schedule  for  first 
year,  255,  25(5 
homogenized      oil      mixtures      in, 

304 
in  asylums,  319 
in    chronic    intestinal    indigestion, 

333 
in  constipation,  337 
in  diarrhea,  328 
in  difficult  cases,  322 
in  inanition,  338 
in  intolerance  to  fat,  336 
in  morasmus,  33!) 
in  simple  acute  diarrheas,  329 
intervals  for,  27ti 
intoxication  in,  321 
laboratory,  282 
loss  of  weight  in,  322 
malt  soups  in.  305 
malted  gruels  in,  305 

milk  in.  304 
mammala  in,  300 
Materna  Graduate  Method,  291 
mineral  salts  in,  270 
mixed,  263 
nasal,  325 
olive  oil  in,  304 
orange-juice  in,  297,  300 
other  foods  allowed,  264 
partial   feeding  with  human  milk, 

264 
practical,  276 
protein  indigestion,  282 
requirements   of,   269 
quantity,   277 
soy  bean  in,  302 
stationary  weight  in,  323 
standardized  gruels  in,  301 
stools  of  infant  in,  317 
substitutes  for  milk,  276 
sugar-poisoning,    acute.    320 
tolerance  for   food,   270 
top-milk  method,  288 
vegetable  broths  in,  303 

purees  in,  303 
vomiting  in,  323 

while     lactation     is     being     estab- 
lished, 259 
foods,  adulteration  of.  231 
premature,  Budin's  rule  for  feeding, 
267,  269 
caloric  needs  of,  266 
Infantile  scurvy,  diet  in,  665 
Infantilism,  intestinal,  diet  in,  343 
Infectious  diseases,  diet  in.  371 
Influenza,  diet  in,  390 
Infusion,  plain  water,  360 

saline,  359,  360 
Injections,    intraperitoneal,    of    sodium 
bicarbonate     in     acidosis, 
673 
Insane,  diet  for,  565 
Insomnia,  diet  in,  553 


Intellectual  faculties,  effect  of  alcohol 

on,   185 
Intermittent    hypersecretion,    diet     in, 

435 
Interstitial    nephritis,   chronic,   alcohol 
in,  547 
diet  in,  545 
in  obesity,  treatment,  645 
Intestine,  absorption  in,  36 
large,  atony  of,  diet  in,  487 
malignant  growths  of,   diet   in,  484 
mucomembranous     catarrh    of,     diet 

in,  485 
nervous  affections   of,   dietetic  treat- 
ment.  487 
operations  on,  diet  after,  708 
passage  of  food  through,  26 
ulcer  of,  diet  in,  483 
Intestinal  catarrh,  acute,  diet  in,  479 
chronic,  diet  in,  479 
diseases,  diet  in,  473 
dyspepsia,  diet  in,  477 
fistula,  feeding  through,  709 
flora,  effect  of  starvation  on,  477 
indigestion,      chronic,      in      children, 

diet  in,  333,  334 
infantilism,  diet  in,  343 
neurasthenia,  diet  in,  487 
obstruction,  acute,  diet  in,  484 

chronic,  diet  in,  484 
secretion,  32 

stasis,  chronic,  diet  in,  493 
Intolerance   to   fat,    infant   feeding   in, 

336 
Intoxication,  coffee,  chronic,  220 

in  infant  feeding,  321 
Intraperitoneal     injections     of     sodium 
bicarbonate     in     acidosis, 
■673 
Intravascular  feeding,   358 
Intubation    in    children,    feeding   after, 
341 
in  diphtheria,  diet  in.  391 
Inosite,  595 
Inulin,  595 
biscuit,  795 

in  diabetes.  597 
Inunctions,  nutrient,   358 
lodin,    158 

and  bromin  waters,  172 
Iodized  junket,  779 
Irish  moss,  147 
and  milk.  781 
blanc-mange.    791 
meat  jellv  with,  791 
Iron,  160 

and  arsenic  waters,  175 
waters,  173 
sulphated,   174 
Iron-containing  foods,   165 
Irrigation,  saline.  359 
Irritability,     gastric,     in    tuberculosis, 
diet  in,  411 


906 


INDEX 


Jacobin  cubes,  797 

Jaundice,  catarrhal,  diet  in,  497 

in  children,  diet  in,  498 
Jeflfries'  gluten  biscuit,  791 
Jelly,  albuminized,  791 
barley,  772 
calf's-foot,  122 
calf's-head,  122 
chicken,  789 
coffee,  790 
for  dyspeptics,  789 
lemon,   790 

diabetic,  798 
meat,  122,  789 
with  gelatin,  791 
with  Irish  moss,  791 
with  tapioca,   791 
without  gelatin,  789 
milk,  791 
oatmeal,   772 
orange,  790 
peptonized  milk,  777 
tapioca,  773 
veal-bone,  789 
wheat  in  eczema,  680 
wine,  790 
Jerusalem  artichoke,  139 
Johns  Hopkins  Hospital  carbohydrate- 
free  diet,  in  diabetes  mel- 
litus,   58^-585 
diet  for,  748 
green  day  diet  in  diabetes  mel- 

litus,  586 
low  protein  diet,  537 
oatmeal    day    diet    in    diabetes 
mellitus,  586 
Joslin's   modification   of   Allen's   treat- 
ment  for   diabetes,    577 
strict  diet  lists  for  diabetes  mellitus, 
578-582 
Junket,  113,  778 
bitter  almond,  779 
cocoa,  778 
coffee,  779 
iodized,  779 
strawberry,  779 
vanilla,  779 
with  egg,  778 

Katfee-hag,  179 
Kakkfe,  diet  in,  666 
Kaoliang,  133 
Karell  diet,  683 
Kefir,  116 

with  kefilac  tablets,  780 
Kidney,  amyloid,  diet  in,  548 

floating,  diet  in,  548 

operations  about,  diet  after,  706 
Klemperer,  test-meal  of,  240 
Kneipp  cure,  688 
Kola  nut,  181 

Krause-Garre   table,   showing  carbohy- 
drate-cellulose   foods,    492 


Kreotoxismus,  217 

Kumiss,  116,  780 

cure,  116,  685 

Labobatoby  feeding  for  infants,  282 
Lactation,    reestablishment    of,    in    in- 
fant  feeding,    253 
Lactic  acid  bacillus  in  milk,  104 
Lactometer,   107 
Lactose,  21,  149 

Ladd's  table  for  milk  modification,  294 
Lakeside     Hospital,     Cleveland,     Ohio, 

diet  of,  749 
Lamb,  124 

cuts  of,  807 
Laparotomies,  diet  in,  699 
after,  700 
before,  699 
Lard,  adulteration  of,  231 
Laryngismus-stridulus,  diet  in,  505 
Laryngitis,  diet  in,  505 
Larynx,   excision  of,   diet  after,   705 
Lathyrism,  220 
Laxative  bread,  774 
Leach's   test   for   detection   of    formal- 

dehyd  in  milk,  109 
Lead  in  food,  234 

poisoning,  chronic,  diet  in,  557 
workers,  gout  in,  631 
Leanness,  diet  in,  659 
Lecithin,  33 
Legs,  diseases  of,  in  obesity,  treatment, 

645 
Legumes,  134 
absorption  of,  39 

composition  of,  table  showing,  137 
digestibility  of,  134 
Legiimin,  202 

Leguminous  foods  in  diseases  of  stom- 
ach, 425 
Lemon    extract,    adulteration    of,    test 
for,  238 
jelly,  790 

diabetic,  798 
whey,  779 
Lemonade,  769 
albuminized,  769 
effervescing,   769 
milk,  779 

peptonized  milk,  778 
Lemons,   142 

Lenhartz's    diet    in    ulcer    of    stomach, 
author's  modification,  451 
Lambert   modification,   449 
Seale  Harris  modification,  450 
Lentil,  137 
Lettuce,  140 

stewed,  795 
Leube-Rosenthal  meat  solution,  787 
Leube's  diet  scale,  in  diseases  of  stom- 
ach, 413 
test  for  determining  motor  power  of 
stomach,  240 


INDEX 


907 


Leukemia,  diet  in,  524 
Levulose,  19,  149 
Lichens,    147 
Limes,   142 
Lime-water,  768 

in  infant  feeding,  275 
Linseed  tea,  769 
Lipins,  23 

Lipolytic  enzymes,  27 
Lipuria,  effect  of  diet  on,  525 
Liqueurs,  187 

adulteration  of,  230 
composition  of,   187 
Liquid  foods  in  gastric  disorders,  422 
Liquors,  malt,  1S7 

action  and  therapeutic  use  of,  196 
composition  of,   189 
Lithemia,  diet  in,  549 
Liver,  abscess  of,  diet  in,  499 
absorption  in,  33 

acute,  yellow  atrophy  of,  diet  in,  499 
amyloid,  diet  in,  499 
cirrhosis  of,  diet  in,  502 
hypertrophic,  diet  in,  502 
with  ascites,  diet  in,  503 
without  ascites,  diet  in,  503 
congestion  of,  diet  in,  498 
diseases  of,  alcohol  in,  496,  503 

diet  in,  495 
fatty,  diet  in,  499 
operations  about,  diet  after,  706 
sausage,  poisoning  from,  218 
syphilis  of,  diet  in,  499 
Lobster    extract,    preparation    of,    for 

sensitization   test,   225 
Locke's  table  of  food  values,  851 
Loeiiand"s  malt-soup  extract,  305 
Low    protein    diet    of    Johns    Hopkins 
Hospital,  537 
test-diet  for  renal  function,  535 
Lungs,  liemorrhage  from,  diet  in,  507 
Lupinosis,  220 
Lyster  griddle  cakes,  792 
waffles,  792 


Magnesium    and    calcium    content    of 

vegetable  foods,  527 
Magnesium-containing  foods,   166 
Maidismus,  diet  in,  668 
Maize,  132 
Malaria,  diet  in,  397 
Malnutrition,  diet  in,  340 
Malt  extract,  205 

composition  of,  205 

liquors,   187 

action  and  therapeutic  use  of,  196 

soups  in  infant  feeding,  305 
Malted  gruels  in  infant  feeding,  305 

milk  in  infant  feeding,  304 
Maltose,  21 
Mammala,  201 

in  infant  feeding,  300 


Manganese,  163 
Mannite,  595 
Marasmus,  diet  in,  339 

nursing  homes  for,  340 
Marine  Hospitals,  diet  in,  754 
Mastication,  24 
Materna    Graduate    method   of    infant 

feeding,  291 
Maternal  nursing,  contraindications  to, 

251,  261 
Matzoon,   117 

Maynard  Ladd's  table  for  milk  modi- 
fication, 294 
Meal  soup,  772 

Meals,   order   and   frequency   of,   influ- 
ence on  digestion,  40 

rest   and   exercise   before  and   after, 
influence  of,  on  digestion, 
42 
Measles,  diet  in,  389 
Meat,  120,  782 

absorption  of,  38 

and  hot  water  cure,  687 

artificial  proteins  made  from,  201 

baking  of,  206 

boiling  of,  206,  782 

brazing  of,  207 

broiling  of,  207,  783 

broth,  785 

canned,  adulteration  of,  232 

composition  of,  table  showing,   125 

cooking  of,  206 
eflFect  of,  207 

cuts  of,  805 

digestibility  of,  120 

extract,  acid,  786 

foods,  relative  digestibility  of,  table 
showing,  121 

frying  of,  207 

general  rules  for  preparing,  782 

horse,  124 

in  diseases  of  stomach,  424 

in   tuberculosis,  405 

jelly,  789 

with  gelatin,   791 
with   Irish  moss,  791 
with  tapioca,  791 
without  gelatin,  789 

juice,  787 

pan-broiling,  783 

powders,   122 

preparations,  121 

raw,  juice,  786 

roasting  of,  206,  783 

solution,    Leube-Rosenthal,   787 

soups  without,  776 

stewing  of,  207 

tender,  cooking  of,  783 
Meat-jellies,  122 
Meat-poisoning,  217 
Medicine,  use  of  alcohol  in,  185 
Melons,  143 
Meningitis,  diet  in,  390 


908 


INDEX 


Menstruation,    effect    of,    on    woman's 

milk,  254 
Mental     conditions,     aberrant,     during 
pregnancy,  diet  in,  350 
work  as  cause  of  gout,  631 
effect  on  metabolism,  53 
Mercuric   chlorid,   acute   nephritis    due 

to,  diet  in,  545 
Mess,    general,    organization    and    ad- 
ministration,   728 
Metabolic  balance  disturbed,  in  infant 

feeding,  320 
Metabolism,  42 

and  energy  of  alcohol,  181,  182 
calcium,  163 

and  tetany,   164 
effect  of  fever  on,  53 
effect  of  beat  on,  53 
effect  of  mental  work  on,  53 
normal,  standards  of,  58 
of  fat,  23 
of  salts,  156 

and  disease,  164 
purin,  66 

respiration   experiments   in,   46 
Metallic  poisons  in  food,  234 
Meteorism,  diet  in,  487 
Metric      and      apothecaries'      measure, 
relative  value  of.  849 
weight,  relative  value,  850 
avoirdupois    weight,     relative    value 
of,  850 
Metropolitan   Hospital,   Blackwell's   Is- 
land,   tuberculosis    infirm- 
ary of,  diet  for,  756 
Microscopic      test      for      detection      of 

heated  milk,   110 
Migraine,  diet  in,  553 
Milk,  93 

absorption  of,  38 

acid,  in  infant  feeding,  298 

test  for,   108 
action  of  heat  on.  96 
adulteration  of,   106 
albuminized,  781 
alkaline   fermentation  of,   101 
almond,  768 
and  eggs,  782 
and  Irish  moss,  781 
and  sugar  with  raw  meat.  788 
as  cause  of  Asiatic  cholera,  214 
of  diarrheal  diseases,  213 
of  diphtheria,  214 
of  scarlet  fever.  214 
of  tuberculosis.  213 
of  typhoid  fever,  214 
bacteria  in,   101 
bitter,   101 
blue,  101 

bottled,  bacteria  in,  276 
butter-,  113 
care  of,  106 
color  of,  100 


Milk,  composition  of,  93,  271 

table  showing,  47 
condensed,   114 

as  infant  food,   115,  297 
cure,  683 

in  diseases  of  stomach,  428 
digestion  of,  100 
delivery  of.    106 
diluents,  781 
diseases  from,  212 
examination  of,  107 
fat  in,  273 

tests  for,   107 
ferments,  96 
flavors  in,   101 
for  diabetics,  796 
formaldehyd  in,  detection  of,  109 
Hehner's  test  for,   109 
Leach's  test  for,   109 
frozen,  97 
handling  of,   106 
heated,  detection  of,  109 

Arnold's  guaiac  method,  109 
Frost    and    Ravenel    microscopic 

test  for,   110 
Storch's  method,  109 
human,  conditions  affecting,  254 
hydrogen    peroxid    in,    detection    of, 

109 
in  tuberculosis,  404 
in  typhoid  fever  diet,  375 
jelly,  791 
lemonade,  779 

malted,   in  infant  feeding,   304 
mixture,  780 

calculation  of  percentages   in,   273 
modification,  279 

at  home,  technic,  295 

Bauer's  method,  295 

Holt's   percentage  method,   287 

laboratory,  282 

Materna  Graduate  method,  291 

Maynard  Ladd's  table,  294 

methods  of  practical  value  in,  279 

top-milk  method,  288 
modified,    caloric    value   of,    determi- 
nation, 267 
modifier,  Deming,  293 
mother's,  modification  of.  2.56 

testing,  256 
pasteurization  of,  97 
peptonized,  cold  process,  777 

effervescent,   777 

gruel,  778 

hot,  777 

jelly,  777 

lemonade,  778 

partially,   777 

specially,  777 

warm  process,  777 
poisons  transmitted  in,  213 
porridge.  779 
predigestion  of,   115 


INDEX 


909 


Milk,    pregnancy    in    cow   and    use   of, 
97 
preparations,   777 
preservatives  in,  107 
production,    104 
products,  93 
proprietary     foods     prepared     from, 

203 
protein  in,  271 

estimation  of,  108 
pun  ill,  779 

peptonized,  778 
red,  101 
ropy.  101 
skim.   111 
slimy,   101 
somatose,   201 
souring  of,   103 
specific  gravity  of,   107 
standards,    105 
sterilization  of,  97 
substitutes    for,    in    infant    feeding, 

276 
sugar  of,  149,  272 
sugar-free,      for      diabetic      feeding, 

796 
tests,  108 

transportation  of,   106 
variations  in,  96 

use  of,  in  certain  skin  diseases,  678 
yoghurt,  116 
Alilk-and-cereal  waters,  781 
Milk-and-cinnamon   drink,    780 
Milk-poisoning,  214 
Millet,  132 
Mineral  matter,  805 
in  feces,  154 
in  principal  organs,  155 
in  sweat,  154 
in  urine,  154 
salts  in  infant  feeding,  270 
waters,   168 
alkaline.  169 
classification,  169 
earthy.   175 
in  gout.  637 
Mixed  infant  feeding,  263 
Modification    of    milk.     See    also    Milk 

modification. 
Modified   milk,  caloric  value  of,  deter- 
mination, 267 
Molasses,  148 

composition   of,   table   showing,   149 
MoUusks,   composition   of,   table   show- 
ing,  129 
Monosaccharids.  19 

Moorehouse's     method     for     estimating 
caloric    value    of    infant's 
food,  267 
Morel,  146 

composition  of,   146 
Morphin-poisoning,     chronic,    diet     in, 
556 


Mosenthal's  accessory  diet  of  foods  rich 
in  carbohydrates,  573 
diet  for  nephritis,  537 
renal  function  test-diet,  534 
starch-free  diet,  571 
tests  of  renal  function,  535 
Moss,  Iceland,  147 

Irish,   147 
Mother,   education   of,   in   infant   feed- 
ing, 251,  261 
nursing,  252 
diet  for,  252 

mental  attitude  of,  effect  on  secre- 
tion of  milk,  260 
Mother's  milk,  modification  of,  256 
Motor  and  secretory  functions  of  stom- 
ach,   disturbances    of,    at 
same    time,    dietetic    test 
for  determining,  241 
power  of  stomach,  determining  of,  240 
Boas'  method,   240 
test-supper,  240 
dietetic  tests  for,  240 
Leube's  method,  240 
starch  retention  test  of  Haus- 
mann,  240 
Mouth,  care  of,  in  typhoid  fever,  382 
Mouth-and-foot  disease,  221 
Muffins,  bran,  for  constipation,  774 
diabetic,  791 
soy  l)ean,  799 
Mulberries,  143 
Mulled  wine,  770 
Mumps,  diet  in,  389 
Murphy  method  of  administering  solu- 
tions by  rectum,  359 
Muscular  activity,  effect  of  alcohol  on, 
182 
energy,  alcohol  as  source  of,   182 
Mushroom-poisoning,   219 
Mushrooms,  146 

composition  of,  146 
Mussels,  poisoning  from,  215 
Mustard,  149 
Mutton,   124 

broth  with  vegetables,  785 

without  meat,  785 
cuts  of,  807 

extract,  preparation  of,  for  sensitiza- 
tion test,  225 
Mytilotoxismus,  215 

Nasal  feeding,  364 
for  infants,  325 
Nausea  after  operations,  diet  in,  700 

treatment,  700 
Navy  hospitals,  diet  in,  752 
rations,  725 
cooking  of.  733 
preparation  of,  732 
Nephritis,   acute,   acidosis   in,  diet  in, 
538 
diet  in,  541 


910 


INDEX 


Nephritis,     acute,     due     to     mercuric 
chlorid,  diet  in,  545 
chronic,  interstitial,  alcohol  in,  547 
diet  in,  545 
parenchymatous,  diet  in,  543 
diabetes  and,  diet  in,  589 
diet  for,  537,  539 
excretion  of  acetic  acid  in,  540 
of  alcohol  in,  541 
of  citric  acid  in,  540 
of  creatinin  in,  540 
of  hippuric  acid  in,  540 
of  phosphoric  acid  in,  540 
of  sulphates  in,  540 
of  urea  in,  540 
of  uric  acid  in,  540 
of  water  in,  539,  542 
of  Xanthin  bases  in,  540 
interstitial,     in    obesity,    treatment, 
645 
Nephrosis,  diet  in,  544 
Nervous    affections    of    intestine,    die- 
tetic treatment,  487 
anacidity  of  stomach,  diet  in,  467 
anorexia,  diet  in,  467 
diseases  in  obesity,  treatment,  646 
dyspepsia,  diet  in,  467 
impressions,    effect    of,    on    woman's 

mills,  254 
subaciditv  of  stomach,  diet  in,  467 
system,   diseases   of,   alcohol   in,   551 
diet  in,  550 
effect  of  alcohol  on,  183,  184 
vomiting,  diet  in,  467 
Neuralgia,  diet  in,  551 
visceral,  diet  in,  552 
Neurasthenia,   intestinal,  diet  in,  487 
New  Zealand  spinach,  140 
Nickel  in  food,  234 

Nipples,  care  of,  in  infant  feeding,  252 
Nitrogen  equilibrium,  61 
Nursing    homes    for    marasmus    cases, 
340 
maternal,   contraindications   to,   251, 

261 
mother,  252 

diet  for,  252 
wet-,  of  infant,  263 
Nut-brown   bread,   774 
Nut-cakes,  soy  bean,  800 
Nutrient      enemata,      351.     See      also 
Enema  nutrient. 
inunctions.  358 
Nutrition  and  growth,  59 
effect  of  borax  on,  200 
of  boric  acid  on,  200 
enzymes    concerned    in    processes    of, 
table   showing,  28 
Nutritious  coffee,  790 

drink   for   delicate  women   and   chil- 
dren, 789 
ratio  of  food,  49 
Nutrose,  201 


Nuts,  144 

composition  of,  compared  with  other 
foods,   table  showing,   145 
table  showing,   144 
digestibility  of,  144 

Oatmeal,  133 

day  diet  in  Johns  Hopkins  Hospital, 
in   diabetes    mellitus,    586 
diet  in  diabetes  mellitus,  580 
gruel,  771 
jelly,  772 

test-breakfast  of  Boas,  240 
water,  770 
with  beef  tea,  786 
Oats,  133 

extract,   preparation   of,    for   sensiti- 
zation test,  226 
Obese,  salad  dressing  for,  775 
Obesity  after  cures  for  pulmonary  tu- 
berculosis, diet  in,  646 
bronchitis  in,  treatment,  645 
causes,  641 
diet  in,  640 

cures  in,  647 
diet-list  for,  843 

diseases    combined    with,    treatment, 
644 
of    circulatory    system    in,    treat- 
ment,  644 
of  legs  in,  treatment,  645 
of  respiratory  system  in,  treatment, 
645 
gout  in,  diet  in,  639,  646 
interstitial    nephritis    in,    treatment, 

645 
nervous   diseases   in,   treatment,    646 
Oertel's  diet  in,  653 
prophylaxis  of,  647 
salad  dressing  for,  776 
skeleton  diet  in,  652 
starvation  diet  in,   653 
treatment,  642 
Ochsner's  treatment  of  peritonitis,  494 
Oertel's  diet  in  obesity,  653 
diet-list   in    circulatory   disturbances 
and  obesity,  657 
Oil,    cottonseed,    adulteration    of,    Hal- 
phen    reaction    for    detec- 
tion of,  239 
mixture,      homogenized,      in      infant 

feeding,   304 
olive.     See  also   Olive  oil. 
sweet-almond,    emulsion    of,    in    gas- 
tric disorders,  153 
Oils,  150 
fatty,  23 

hydrogenation  of,  150 
Oleomargarin,  154 
testing,  112 

Waterhouse  test  for,  113 

Olive  oil,  adulteration  of,  231 

in  cholelithiasis,  151 


INDEX 


911 


Olive  oil  in  chronic  constipation,  153 
dysentery,  152 
in  gall-stone  colic,  153 
in  gastric  disorders,  151 
in  infant  feeding,  304 
in  stricture  of  esophagus,  151 
in  treatment  of  diseases,  151 
Olives,  143 
Onions,  141 

Operations     about     gall-bladder,     diet 
after,  706 
head,  diet  after,  704 
kidney,  diet  after,  706 
liver,  diet  after,  706 
pancreas,  diet  after,  706 
bowels  after,  care  of,  701 
diet  after,  700 

before,  69!) 
for  cleft  palate,  diet  after,   705 
for  harelip,  diet  after,  705 
nausea  after,  diet  in,  700 
on  esophagus,  diet  after,  705 
on  intestine,  diet  after,  708 
on  stomach,  diet  after,  706 
preparation  for,  diet  in,  699 
shock  after,  dietetic  management  of, 

702 
surgical,  in  diabetes,  diet  in,  590 
thirst  after,  treatment,  701 
vomiting  after,  diet  in,  700 
Orange  jelly,  790 
Orangeade,  769 
Orange- juice    in    infant    feeding,    297, 

300 
Oranges,  142 
Orgeat,  770 

Osteomalacia,  diet  in,  677 
Overeating  as  cause  of  gout,  631 
Oxalic-acid  content  of  foods,  527 
Oxaluria,  effect  of  diet  on,  525 
Oxidases,  27 
Oxidizing  enzymes,  27 
Oxyuris  vermicularis,  211 
Oyster  juice,  785 

stew.  776 
Oysters,   127 

as  cause  of  typhoid  fever,  215 
peptonized,  787 

Paxpitatiox,  in  diseases  of  heart,  diet 

in,  512 
Pan-broiling  meat,  783 
Pancakes,  aleuronat,  794 
cocoanut,  794 
gluten,  791 
soy  bean,  800 
Pancreas,  diseases  of,  diet  in,  503 
operations  about,  diet  after,  706 
Pancreatic  fistula,  diet  in,  709 
juice,  31 

ferments  in,  amounts,  31 
Paralysis,     postdiphtheritic,     diet     in, 
392 


Paraphenatolcarbamid,     as     substitute 
for  sugar  in  diabetes,  596 
Parasites  in  food  or  drink,  210 
Parasitic  diseases,   212 
Parenchymatous      nephritis,      chronic, 

diet  in,  543 
Parotitis,  prevention  of,  during  rectal 

feeding,  355 
Parsnips,  139 

Pasteurization  of  milk,  97 
Pasteurized  milk,   microscopic  test  for 
detection  of,    110 
standards  for,  105 
Peaches,    143 
Peanut,   134,  138 
flour,  796 

in  diabetes,  597 
Pear,  alligator,  143 
Pears,   143 
Peas,   134.   137 
Pectin,  142 
Pellagra,  diet  in,  668 
Pelvic    contraction,    diet    in,    Prochow- 

nick's,  348 
Penzoldt's  diet  in  diseases  of  stomach, 
418 
diet-lists,  418 

table   showing   digestibilitv    of    food, 
417 
Peppers,   149 
Pepsin,  30 

in  infant  digestion,  35 
Peptone  products,  201 
Peptonized  beef,  787 
milk,  cold  process,  777 
effervescent,  777 
gruel,  778 
hot,  777 
jelly,  777 
lemonade,  778 
partially,  777 
punch,   778 
specially,  777 
warm  process,  777 
oysters,  787 
Percentages  and  calories,  270 
Perfect  wines,  192 
Perforation,  in  typhoid   fever,   diet  in, 

383 
Peritonitis,  acute,  diet  in,  494 
chronic,  diet  in,  495 
diet  in,  494 
Pernicious  anemia,  diet  in,  520 

vomiting,  in  pregnancy,  diet  in,  349 
Pertussis,  diet  in,  389 
Phenolsulphonephthalein  test  for  renal 

function,    531 
Phosphaturia,  effect  of  diet  on,  525 
Phosphoric    acid,"  excretion    of,    in    ne- 
phritis, 540 
Phosphorus,  159 

Phosphorus-containing  foods.   165 
Phosphorus-poisoning,   221  , 


912 


INDEX 


Photographic     method     of     measuring 

surface  of  body,  57 
Phthisis,  diet  in,  408 
Pigeons,   124 
Pigments,  bile-,  function  of,  33 

urinary,    excretion   of,    in    nephritis, 
540 
Plasmon,  201 
Plastered  wine,  229 
Pleurisy,  diet  in,  504 
Plums,  143 
Pneumonia,  alcohol  in,  508 

diet  in,  507 

fronj  infected  bacon,  218 

in  children,  alcohol  in,  509 
diet  in,  508 
Poisoning,  cheese-,  215 

chestnut-,  219 

fish-,  216 

food-,  acute,  210 

from  liver  sausage,  218 

grain-,  219 

lead,   chronic,  diet  in,   557 

meat-,  217 

milk-,  214 

morphin,   chronic,  diet  in,   556 

mushroom-,  219 

mussel-,  215 

phosphorus-,  221 

potato-,  220 

sausage-,  217 

sodium  chlorid,  361 

sugar-,  acute,  in  infant  feeding,  320 
Poisons,  food-,  diseases  caused  by,  209 

metallic,  in  food,  234 

transmitted  in  milk,  213 
Polysaccharides,  21 
Pork,  124 

cuts  of,  808 

extract,   preparation   of,   for   sensiti- 
zation test,  224 
Porridge,  milk,  779 
Porter.  189 

Post-anesthetic  acidosis,  diet  in,  672 
Postdiphtheritic  paralysis,  diet  in,  392 
Posthemorrhagic    anemia,    acute,    test 

in,  519 
Post-operative  acidosis,  diet  in,  672 
Potassium-containing  foods,   165 
Potato,  138 

flour  cakes,  792 

soup,  cream  of,  776 

sweet,  138 
Potato-poisoning,  220 
Predigestion  of  milk,  115 
Pregnancy,  aberrant  mental  conditions 
in,  diet  in,  350 

diet  in,  347 
in  obesity,  347 

effect  of,  on  woman's  milk,  254 

gingivitis  in,  diet  in,  349 

in  cow  and  use  of  milk,  97 

lowered  urea  output  in,  diet  in,  349 


Pregnancy,  obesity  in,  diet  in,  347 
pernicious     vomiting     in,     diet     in, 

349 
salivation  in.  diet  in,  349 
special  diseas*»s  of,  diet  in,  349 
Premature     infant,     Budin's    rule     for 
feeding,  267,  269 
caloric  needs  of,  266 
Preservation  of  food,  198 

by  antiseptic  chemical  agents,  199, 

200 
by  canning,  199 
by  drying,  199 
by  exclusion  of  air,  199 
by  exposure  to  cold,  199 
by  salting,  200 
by  spices,  200 
by  sugar,  200 
by  vinegar,  200 
Preservatives.  232 

benzoic    acid,    test    for    detection   of, 

236 
bisulphate  of  sodium,  233 
borax,  232 

test  for  detection  of,  236 
boric  acid,  232 

test  for  detection  of,  236 
formaldehyd.  233 

detection  of,  test  for,  236 
in  milk,  detection  of,  109 
Hehner's  test  for,   109 
Leach's  test  for,   109 
hydrogen  peroxid,  234 
in  milk,  107 

saccharin,  test  for  detection  of,  230 
salicylic  acid,  233 

test  for  detection  of,  235 
simple  tests   for  detection  of,   234 
sulphite  of  sodium.  233 
sulphurous  acid,  233 
Prison  diet.  735 
American,  744 
Dunlop's,  737 
English,  744 
French,  746 
in    criminal    lunatic    department, 

741 
ordinary,  745 
Prussian,  747 
Prochownick's    diet    in    pelvic    contrac- 
tion, 348 
Proctoclysis,  Murphj's  method,  359 
Production  of  milk,  104 
Prophylaxis  of  obesity,  647 
Proprietary  foods,  artificial,  203 
composition  of,  204,  205 
farinaceous,  203,  204 
prepared  from  cow's  milk,  203 
Proso,  132 

Protective  enzymes,  27 
Protein,  17,  803 
absorption  of,  38 
American  classification  of,  18 


12iDEX 


913 


Protein,    amount   required    in    athletic 
traininji:,  2oO 
artificial,  made   from  meat,  201 

from  vegetables,  202 
concentrated.   11*8 
diet,  high,  03 
low,  t)2 

objections  to,  63 
value  of,  63 
digestion,  65 

food,   superior  and  inferior,   19 
in  milk,  271 

estimation  of,  108 
in  vegetables,  130 

low,   diet,   of   .Fohns   Hopkins   Hospi- 
tal, 537 
test-diet,   for   renal   function,   535 
optimum,  6-t 
portions,  89 

table  showing,  90 
quantitative    comparison    of    amino- 
acids   obtained   by    hydro- 
lysis  from,   64 
requirements,  60,  77 

of  infant,  269 
sparers,  18 

specific  dynamic  action  of,  68 
Protein-splitting  enzymes,  26 
Proteolytic  enzymes,  26 
Prunes,   143 
Pruritus,  diet  in,  682, 
Prussian  prison  diet,  747 
Psoriasis,  diet  in,  682 
Psychologic  action  of  alcohol,   185 
Ptomain-poisoning,  210 
Ptyalin,  29 

Public  institutions,  dietaries  in,  734 
Pudding,  aleuronat  and  suet,  794 
almond,  703 
cocoanut,  795 
egg,  T82 
gluten,  701 
spinach,  797 
Puerperium,  diet  in,  349 
Pulled  bread,  774 

Pulmonary      tuberculosis,      cures      for. 
obesity  after,  diet  in,  646 
Pumpernickel,   132 
Pumpkins,   141 
Puncli,  milk,  779 
Purees,    vegetable,    in    infant    feeding, 

303 
Purin  bodies  in  food  materials,  633 

metabolism,  66 
Purpura,  hemorrhagic,  diet  in,  524 
Pyelitis,  diet  in,  549 
Pyelonephritis,  diet  in,   549 
Pylorospasm,   in  children,  diet  in,   328 

olive  oil  in,  152 
Pylorus,    hypertrophy    of,    in    children, 
diet  in,'  328 
stenosis  of,  olive  oil  in,   151,  152 
ulcer  of,  olive  oil  in,  152 


Rajjbit,  124 
Kabies,  diet  in,  399 
Eacahout,  202 

des  Arabes,  772 
Pace,  relation  of  food  to,  54 
Rachitis,  diet  in,  341 
Radishes,  139 
Raisins,  143 
Raspberries,  143 
Rations,  army,  710 

Allies',  comparison,  717 
Filipino,  714 
foreign,  723 
garrison,  713 
haversack,  714 
in  tropics,  719,  720 
travel,  714 
calculation  of,  75 
navy,   725 

cooking  of,  733 
preparation  of,   732,   733 
of   liquid  food,   ideal,   90 
tables  for  selection  of  balanced,  78- 
83 
Raveuel    and     Frost    microscopic    test 
for    detection    of    heated 
milk,  110 
Raw  beef,  methods  of  preparing,   788 
soup,  788 
meat  juice,  786 

with  milk  and  sugar,  788 
milk,  standards  for,   105 
Reaction,   Halphen,   for   cottonseed  oil, 

239 
Recipes.  768 

for  foods  for  diabetics,  791 
Rectal   feeding,   351.     See   also   Enema, 
nutrient. 
saline   irrigations,   359 
Rectum,  feeding  by,  351,  359 

Murphy     method     of     administering 
solutions  by.  359 
Red  milk,  101 

stools  in  infant  feeding,  318 
Refractory  patients,   feeding  of,   364 
Pienal  calculi,  diet  in,  549 
function  test-diet  for,  534 

tests  for,  530 
glycosuria,  569 
Rennin,  30 

in  infant  digestion.  35 
Renovated  butter,   112 

testing,  112,  113 
Respiration    experiments     in    metabol- 
ism, 46 
Respiratory  calorimeter,  44 

organs,  diseases  of,  diet  in,  504 
stimulant,   alcohol   as,    183 
system,  diseases  of,  in  obesity,  treat- 
ment,  645 
Rest    and    exercise    before    and    after 
meals,  influence  of,  on  di- 
gestion, 42 


914 


INDEX 


Rest  cure  in  diseases  of  stomach,  427 
of  Weir-Mitchell,  557 
alcohol   in,   5&2 
Rhabdonema    intestinale,    212 
Rheumatism,  acute,  diet  in,  393 

chronic,  diet  in,  39-4 
Rheumatoid  arthritis,  diet  in,  640 
Rhubarb,  140 
Rice,  133 

extract,   preparation    of,    for   sensiti- 
zation test,  226 
water,  770 
Rickets,  diet  in,  341 
Riegel,  test-dinner  of,  240 
Roasting  meat,  206,  783 
Robert  Garrett  Free  Hospital  for  Chil- 
dren,   Baltimore,    diet    of, 
763 
Roborat,  202 
Roots,   138 

absorption  of,  39 

composition   of,   table   showing,    139 
Ropy  milk,   101 
Rough  wines,  192 
Rye  bread,  132 

Riibner's    diet    in    intestinal    diseases, 
474 
table     illustrating     absorbability     of 
foods,  38 
Rum,  187 
Russian  dressing,  797 

Saccharin,  149,  205 
as  preservative,  test  for  detection  of, 

236 
as   substitute  for  sugar   in  diabetes, 
595 
Sahli's  method  of  determining  at  same 
time  disturbances   of  mo- 
tor   and    secretory    func- 
tions  of   stomach,   241 
Saint    Paul's    School,    Baltimore,   chor- 
ister   bovs    in,    diet    for, 
756 
Salad  dressing  for  obese,  775 

tomato  jelly,  798 
Salicylic  acid  as  preservative,  233 

test  for  detection  of,  235 
Saline  infusions,  350,  360 
irrigations,   359 

rectal,  359 
springs  in  gout.  637 
Saliva,  29 

secretion  of,  34 
Salivary  glands,  34 
Salivation  in  pregnancy,  diet  in,   349 
Salt  content  of  foods,  691 
table  showing,    156 
in  vegetables,   130 

percentage      of,      found      in      foods, 
Zweig's     tables     showing. 
471 
test  for  renal  function,  533 


Salt-free  diet,  688 
Salts,  17,   154 
metabolism,   156 

and  disease,   164 
mineral,  in  infant  feeding,  270 
Salzer,  double  test-meal  of,  240 
Sauces,  150 
Sauerkraut,   140 

Sausage,  liver,  poisoning  from,  218 
Sausage-poisoning,  217 
Saxin  as   substitute   for   sugar  in   dia- 
betes, 596 
Scarlet  fever,  diet  in,  387 

milk,  as  cause,  214 
Schmidt     and     Strassburger     test-diet, 
241 
test-diet,  242 
Schroth's  cure,  687 
Scorbutus,  diet  in,  664 
Scurvy,    affinities    and    pathologic    fea- 
tures   of,    table    showing, 
662 
diet  in,  664 
in  adults,  diet  in,  604 
infantile,  diet  in,  665 
Second  Hospital  for  Insane,  Maryland, 

diet  for,  757 
Secretin,  33 
gastric,  30 
Secretion,  effect  of  alcohol  on,  184 
gastric,  effect  of  alcohol  on,  184 
intestinal,  32 
Secretory    function    of    stomach,    test- 
meals   to  determine,   239 
Senile  heart,   alcohol  in,  515 

diet  in,  513 
Sensitization,   food,  221 

preparation   of   barlev   extract   for 
test,  226 
of  beef  extract  for  test,  224 
of    cow-casein    extract    for    test, 

227 
of  crab  extract  for  test,  225 
of    egg   white    extract    for    test, 

227 
of  extracts  for  tests,  224 
of  fish  extract  for  test,  225 
of   lobster   extract   for   test.   225 
of  mutton  extract  for  test,   225 
of  oats  extract  for  test,  226 
of  pork  extract  for  test,  224 
of  rice  extract  for  test,  226 
of    strawberry   extract    for   test, 

226 
of  tomato  extract  for  test,   226 
of  wheat  extract  for  test,  225 
skin  tests  for,  222 
Sex,  relation  of  food  to,  55 
Shaddocks,  142 
Shellfish,  127 

Sherman  and  Gettler  table  showing 
acid  excess  value  of  foods, 
74 


I^DEI 


915 


Shock,  diet  in,  702 
Silica,  1(33 

Silver  nitrate  in  ulcer  of  stomach,  445 
Singers,  diet  for,  242 
Sippy's    diet,    moditied,    in    mild    cases 
of   peptic  ulcer,  458 
treatment  of  peptic   ulcer,   454 
Sitotoxismus,  219 
Size   and   weight  of   body,   relation   of, 

food  to,  55 
Skeleton  diet  in  obesity,  652 
Skim  milk,  111 
Skin,  diseases  of,  diet  in,  678 
use  of  milk  in,  678 
surface,   relation   of   food   to.   55 
tests  for  food  sensitization,  222 
Sleep,  disturbed,  diet  in,  553 
Slimy  milk,   101 
Small-pox,  diet  in,  386 
Smithies'      diet      in      dyspepsia      and 
chronic    enterocolitis    due 
to  infecting  protozoa,  483 
in  ulcer,  459 
Sodium  benzoyl-sulphonic-imid,  as  sub- 
stitute  for   sugar    in   dia- 
betes, 5*J6 
bisulphate   of,   as   preservative,   233 
chlorid  poisoning,  361 
waters,   171 
simple,  171 
Sodium-containing  foods,  165 
Soft-cooked  eggs.  781 
Somatose.    122,  202 

milk,  201 
Sorghum,  133 
Sorrel,  140 
Sotip,  beef,  raw,  788 
cream-of-celery,   776 
cream-of-potatb,   776 
cream-of-tomato.  776 
from  stock,  784 
malt,  in  infant  feeding.  305 
meal,  772 
stock,  784 

from  beef  extract,  784 
tapioca,  773 
tomato,  707 
sweetbread.  785 
vegetable.  776 
Soups  for  diabetics.  797 
general  rules  for,  784 
without  meat.  776 
Souring  of  milk.  103 
Soy  bean,  135 

as  breakfast  food,  800 
au  gras,  801 
bread,  801 
broths,  799 
cakes,  800,  801 
cheese.  800 
cookery,  798 
flour,   136 
grilled,  801 


Soy  bean  gruels,  799 
in  diabetes,  798 
in  infant  feeding,  302 
muthns,  799 
nut  cakes,  800 
pancakes,  800 
with  butter,  801 
Sparkling  wines,   192 
Speakers,  diet  for,  242 
Specific  gravity  of  milk,   107 
Spices,   149,    l."iO 

adulteration  of,  231 

test  for,  239 
in  preservation  of  food,  200 
Spinach,    140 

New  Zealand,  140 
pudding,  797 
Spirits,  186 

Springs,  saline,  in  gout,  637 
Sprue,  diet  in,  398 
Squash,  141 

Standards  for  milk,   105 
Starch    retention    test    of    Hausmann, 

240 
Starch-free  diet  in  diabetes,  571 
Starch-splitting  enzymes,  27 
Starvation  diet  in  obesity.  653 
efl'ect  of,  on  intestinal  flora,  477 
treatment    of    diabetes,    diet    follow- 
ing, 590-595 
Stasis,  intestinal,  chronic,  diet  in,  493 
Statistical  report  of  food  consumption 

in   training  camps,   716 
Steapsin,  32 

in  infant  digestion,  35 
Stenosis  of  duodenum,  olive  oil  in,  152 

of  pylorus,  olive  oil  in,  151,  152 
Sterilization  of  milk,  97 
Stew,  oyster,  776 
Stewed  lettuce,  795 
Stewing  meat.  207 
Stimulants.  167 

Stomach,  atony  of,  diet  in,  439 
diet-list  for,  840 

with  hypochlorhydria,  diet  in,  441 
atrophic  catarrh  of,  diet  in,  433 
carcinoma  of,  diet  in,  463 
dilatation  of,  diet  in,  437 
diet-list  for,  839 
in  children,  diet  in,  327 
olive  oil  in,  151 
diseases  of.  Boas'  diet  in,  427 
diet  in,  412 
emulsion    of    sweet-almond    oil    in, 

153 
fast  cure  in,  429 
forced  feeding  in,  428 
gavage  in.  428 
grape  cure  in,  428 
Leube's  diet  scale  in,  413 
milk  cure  in,  428 
olive  oil  in,  151 
rest  cure  in,  427 


916 


INDEX 


Stomach,  diseases  of,  special  cures  in, 
427 
fistula  of,  feeding  through,  709 
hemorrhage  from,  diet  in,  461 
gelatin  in,  462 
hot-water  enema  in,  462 
salt  solution  in,  462 
hyperacidity  of,  diet  in,  469 
in  infant  digestion,  34 
motor    and    secretory   functions,    dis- 
turbances    of,     at     same 
time,  dietetic  test  for  de- 
termining, 241 
power   of,  dietetic  tests  for   deter- 
mining. 240 
nervous  anacidity  of.  diet  in,  467 
disorders  of,  diet  in,  467 
subacidity  of,  diet  in,  467 
operations  on,  diet  after.  706 
passage  of  food  from.  25 
secretory   function   of,   test  meals  to 

determine,   239 
ulcer  of,  diet  in,  442 

dietetic  test  in  diagnosis,  241 
diet-list  for,  841 
hemorrhage  in,  diet  in,  442 
Stomatitis,  in  children,  diet  in,  326 
Stools,  black,  in  infant  feeding,  318 
biackish-brown,     in     infant     feeding, 

318 
brown,  in  infant  feeding,  3 IS 
green,  in  infant  feeding,  318 
of  infant,  in  infant  feeding,  317 
red,  in  infant  feeding,  318 
white,  in  infant  feeding,  318 
Storch's  method  for  detection  of  heated 

milk,   109 
Stout,   189 

Strassburger  and  Schmidt,  test-diet,  241 
Strauss'  diet  in  enteroptosis,  466 
Strawberries,  143 

Strawberry  extract,  preparation  of,  for 
sensitization  test,  226 
junket,  779 
Stretched  butter,  231 
Stricture    of    esophagus,    olive    oil    in, 

151 
Strong  dry  wine,  191 

sweet  wine,   192 
Strongylus   duodenale,   211 
Subacidity,   nervous,    of    stomach,    diet 

in,  467 
Subcutaneous  feeding,  358 
Substitutes  for  sugar  in  diabetes,  595 
Succus  carnis,  787 
Suet  and  aleuronat  pudding,  794 
Sugar,  147 

and  milk  with  raw  meat.  788 

cane-,  148 

diseases  caused  bv.  220 

fruit-,   149 

grape-,  19,  149 

in  milk,  272 


Sugar   in  preservation  of  food,  200 
in  wine,   191 
of  milk,  149 

relation  of,  to  athletic  training,  245 
substitutes  for,  in  diabetes,  595 

Sugar-free    milk    for    diabetic    feeding, 
796 

Sugar-poisoning,  acute,  in  infant  feed- 
ing, 320 

Sugar-splitting  enzymes,  27 

Sulphates,    excretion    of,    in    nephritis, 
540 

Sulphite    of    sodium    as    preservative, 
233 

Sulphur,  159 

Sulphur-containing  foods,   166 

Sulphurous  acid  as  preservative,  233 
waters,  173 

Suppositories,  food,  358 

Suralimentation   in   tuberculosis,   412 

Surface    area    of    body,    photographic 
method   of   measuring,   57 

Surgical  cases,  dietetic  manasrement  of, 
699 
operations  in  diabetes,  diet  in,  590 

Sutherland's  diet  for  chronic  constipa- 
tion, 492 

Sweat,  mineral  matter  in,  154 

Sweet  potato,  138 

Sweet-almond  oil,  emulsion  of,  in  gas- 
tric disorders,  153 

Sweetbread  soup,  785 

Syphilis  of  liver,  diet  in,  499 

Syrup,  148 

composition  of,  table  showing,  149 

TAiiAEiND  water,  769 
Tannic  acid.  178 
Tapeworm.  210 
Tapioca  jelly.  773 

meat  jelly  with,  791 

soup,  773 
Tea,  177 

adulteration  of,  230 

composition  of,  178 

facing,  230 

beef,  785,  786 

flaxseed,  769 

linseed.  769 
Teeth  and  diet.  313 
Temperature   of   food,   influence   of,   on 

digestion,  42 
Test  for  renal  function.  530 
Test-breakfast  of  Ewald  and  Boas,  239 

oatmeal,  of  Boas,  240 
Test-diet  for   renal   function,   534 

low  protein,   for  renal  function,  535 

of  Schmidt,  242 

and  Strassburger,  241 
Test-dinner  of  Riegel,  240 
Testing  mother's  milk,  256 

oleomargarin,   112 

renovated  butter,   112,   113 


INDEX 


917 


Test-meal,  double,  of  Salzer,  240 
of  Germain  S€e,  240 
of  Klemperer,  240 

to    determine    secretory    function    of 
stomach,  231* 
Test-supper  of  Boas,  240 
Tetanus,  diet  in,  398 
Thea,  177 

Theobroma  cacao,  180 
Theobromin,   180 
Thirst,     after     operations,     treatment, 

701 
Tobacco,  effect  of,  on  digestion,  35 
in  diseases  of  heart,   511 
in  gastric  disturbances,  427 
Tomato    extract,    preparation    of,    for 
sensitization    test,    226 
jelly    salad,    798 
soup,  797 
Tomatoes,   140 
Top-milk    method    of    infant    feeding, 

288 
Torrified  bread,   in   diabetes,   596 
Toxic  conditions,  diet  in,  556 
Training  camps,   food  consumption  in, 

statistical   report,   716 
Transportation  of  milk.  106 
Travel  rations,  714 
Treacle,  148 

composition   of,   table   showing,   149 
Trichiniasis,  212 
Trichocephalus   dispar,   211 
Trichomonas,  210 
Triglycerids,  23 
Tropics,  army  rations  in,  719 
diet  for  soldiers  in,  718-720 
Tropon,  201 
TruiSe,  146 

composition  of,  146 
Trypsin,  31,  33 

in  infant  digestion,  35 
Tuberculosis,    advanced    cases,   diet   in, 
408 
alcohol  in,  i06 
beverages  in.  407 
bread  in,  406 
cereals  in,  406 
diet  in,  399 
diet-list  for,  845 
eggs  in,  404 
fats  in,  406 
fever  in,  diet  in,  411 
fish  in,  406 

foods  to  be  used  in,  404 
forced  feeding  in,  412 
fruit  in,  406 

gastric  irritability  in,  diet  in,  411 
infirmary,  diet  for,  756 

Metropolitan       Hospital,       Black- 
well's  Island,  diet  in,  756 
meat  in,  405 
milk  as  cause.  213 
in,  404 


Tuberculosis,  number  of  meals  in,  407 
pulmonary,  cures  for,   obesity  after, 

diet  in,  646 
suialimentation  in,  412 
vegetables  in,  406 
Tubers,  138 

absorption  of,  39 

composition  of,  table  showing,  139 
Tumors,  ductless  glands,  diet  and,  676 
Turmeric  in  food,  test  for  detection  of, 

237 
Turnips,  139 

Typhoid  fever,  atypical,  diet  in,  385 
care  of  mouth  in,  382 
complicated,  diet  in,  385 
convalescence  in,  diet  in,   384 
diet  in,  371 
digestive  disturbances   in,   diet  in, 

383 
hemorrhage  in,  diet  in,  383 
milk  as  cause,  214 
oysters  as  cause,  215 
perforation  in,  diet  in,  383 
Typhus  fever,  diet  in,  386 
Tyrotoxicon,  215 
Tyrotoxismus,  215 

Ulcer  of  duodenum,  diet  in,  483 
of  intestine,  diet  in,  483 
of  pylorus,  olive  oil  in,   152 
of  stomach,  diet  in,  442 

dietetic  test  in  diairnosis,  241 
diet-list  for,  841 
hemorrhage   in,   diet    in,   442 
Unclassified  diseases,  070 
Unconscious    patients,    feeding   of,    364 
Urea,  excretion  of,  in  nephritis,  540 
output,   lowered,    in   pregnancy,   diet 
in,  349 
Uric    acid,    excretion    of    in    nephritis, 

540 
Uric-acid  diathesis,  diet  ^n.  549 
Urinary     pigments,     excretion     of,     in 

nephritis,  540 
Urine,  mineral  matter  in,  154 

relation  to  food,  525 
Urticaria,  diet  in,  681 
Uterus,   effect   of   diet  on   development 
and  structure  of.  350 

Vanilla  extract,  adulteration  of,  test 
for,  238 

junket,  779 
Veal,   124 

broth,  785 

cuts  of,  807 
Veal  'lone  jelly,  789 
Vegetable  broths  in  infant  feeding,  303 

days  diet  in  diabetes  mellitus,  585 

fats,  digestibility  of,  39 

foods,  129 

classification,  130 

purees  in  infant  feeding,  303 


918 


INDEX 


Vegetable  soup,  776 
Vegetables,  775 

artificial  proteins  made  from,  202 

canned,  adulteration  of,  232 

carbohydrates  of,   129 

concentrated,   198 

digestibility  of,   130 

effect  of  cooking  on,  208 

extractives  in,  130 

fats  in,  130 

general  rules  for  cooking,  775 

green,   139 

absorption  of,  39 

composition  of,  table  showing,  141 

digestibility  of,  139 

in  tuberculosis,  406 

protein  in,  130 

salt  in,  130 

sauce  for,  775 

time  table  for  cooking  in  water,  775 

water  in,   130 

with  mutton  broth,  785 
Vegetarian   diet   for    carcinoma,   Bulk- 
ley's,  674 
Vegetarianism,   141 
Venison,   124 
Vertigo,  diet  in,  554 
Vesical  calculi,  diet  in,  549 
Vinegar,  150 

adulteration  of,  test  for,  239 

in  preservation  of  foods,  200 
Visceral  neuralgia,  diet  in,  552 
Viscogen,  100 
Vitamins,  72,  659 
Vomiting  after  operations,  diet  in,  700 

cyclic,  in  children,  diet  in,  325 

in  infant  feeding,  323 

nervous,  diet  in,  467 

pernicious,  in  pregnancy,  diet  in,  349 
Von  Noorden's  diet  in  chlorosis,  523 
in   diabetes   mellitus,   627-629 

diet-list     for     diseases     of     stomach, 
423 

green  days  diet  in  diabetes  mellitus, 
585 

oatmeal    diet    in    diabetes    mellitus, 
586 

Waffles,  lyster,  792 

Walnuts,  145 

War  dieting,  883 

Warm  process  peptonized  milk,  777 

Water,  17,  167 

absorption  of,  167 

albumin,   769 

apple,  769 

barley,  133,  770 

cures,  diet  at.  176 

excretion  of  in  nephritis,  539,  542 

in  vegetables,  130 

intake   and   test  for   renal   function, 
533 

lime,  768 


Water,  oatmeal,  770 
rice,  770 
tamarind,  769 
Waterhouse  test  for  oleomargarin,  113 
Waters,  acratothermal,  176 
alkaline  acidulous,  169 
muriated,  170 
saline,   170 
arsenic  and  iron,  175 
bitter,   173 

bromin  and  iodin,  172 
indifferent,   176 
iodin  and  bromin,   172 
iron,  173 

and  arsenic,  175 
sulphated,   174 
mineral,  168 
alkaline,  169 
classification,  169 
earthy,  175 
sodium  chlorid,  171 

simple,  171 
sulphurous,  173 
Weaning  of  infant,  262 
Wegele's    diet    for    atony    of    stomach 
with        hyperchlorhydria, 
441 
for   atrophic   catarrh   of   stomach, 

434 
for  carcinoma  of  stomach,  464 
for  chronic  constipation,  491 

diarrhea,  489 
for  dilatation  of  stomach,  438 
for  hemorrhoids,  488 
for  hyperacidity  of  stomach,  473 
for  hypersecretion,  436 
for  ulcer  of  stomach,  445 
Weight   and    height   at   different   ages, 
tables  for,  649 
loss  of,  in  infant  feeding,  322 
stationary,  in  infant  feeding,  323 
Weights  and  uieasures,  849 
Weir-Mitchell  rest  cure,  557 

alcohol  in,  562 
Wet-nursing,  263 
Wheat,   131 
bread,  132 

extract,   preparation   of,    for   sensiti- 
zation test,  225 
jelly  in  eczema,  680 
Whey,  779 
cure,  685 

cream-of-tartar,  779 
grape  juice,  779 
lemon,  779 
wine,  779 
Whisky,  186 

White  stools  in  infant  feeding,  318 
Whole-wheat  bread,  774 
Whooping-cough,  alcohol  in,  390 

diet  in,  389 
Wine,  190 

acids  in,  191,  192 


INDEX 


919 


Wine,   action   and   therapeutic   use   of, 
19U 

adulteration  of,  21'J 

alcohol  in,  1*J1 

American,      composition      of,      table 
showing,   l'J'3,    194 

aromatic,  192 

ethers  in,  191 

extractives  in,    191 

fortified,    191,   190 

glycerin  in.  191 

jelly,  790 

mulled,  770 

perfect,   192 

plastered,  229 

rough,  192 

sparkling,   192 

strong  dry,   191 
sweet,  192 

sugar  in,   191 

varieties  of,  191 

whey,  779 
Women,   delicate,    nutritive   drink   for, 
789 


Xantiun    bases,    excretion    of,    in    ne- 
phritis, 540 

Yam,  138 

Yellow    atrophy    of    liver,    acute,    diet 
in,  499 
fever,  diet  in,  396 
Yoghurt  milk,   1 10 
Yolk  cure,  in  diabetic  mellitus.  GS6 

Zi.Nc  in  food,  234 

Zweig's  diet   in   achylia  gastrica,  435 
in  chronic  intestinal   eatarrh  with 
constijiatioii,   480 
witli   diarrhea.   481 
in  dilatation  of  stomacii  with  an- 

acidity,  439 
in  enteroptosis,  466 
in  gastric  carcinoma,  464 
in  mucomembranous  colitis.  486 
tables    showing    percentage    of    salt 
found  in  foods,  471 
Zwieback,   744 
Zymogen,  30 


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